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Nurses’ Notes 0900: A client on the medical-surgical unit is 2 days status post hysterectomy. Client reports pain is currently an 8/10 and requests pain medication. Physical Exam: General: wincing Respiratory: bilateral breath sounds clear Cardiovascular: S1, S2, no murmur or rub Gastrointestinal: minimally tender, no guarding Skin: warm, dry 1030: Client states pain is now 3/10. The client states, “I know I should quit, but I could really use a cigarette right now. I haven’t had one since I arrived.” 1130: RN called to the client’s room. The client is reporting an acute onset of shortness of breath. Client also reports substernal chest pain that radiates to the jaw. Physical Exam: General: anxious, agitated Respiratory: tachypnea, coughing Cardiovascular: tachycardic Skin: warm, dry For each potential nursing action, click to specify if the potential action is urgent, non-urgent, or contraindicated for the client. Potential Order Urgent Non-Urgent Contraindicated Administer O2 by nasal cannula. Educate the client on the importance of smoking cessation. Prepare to administer a thrombolytic. Prepare the client for a CT angiogram of the chest. Prepare to initiate 2 L of IV fluids.
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HEALTH SCIENCE
NURSING

 
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