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11/23/XX 0230 55 y/o male recently diagnosed with influenza A and pneumonia. Presented to the emergency department (ED) accompanied by his wife with worsening shortness of breath, fever, productive cough, green sputum, and new onset altered mental status. —J. Waymire, MD.Date/Time ​ Nurses’ Notes 11/23/XX 0234 ​ Vital signs: T 99 °F (37.8 °C); P 114, reg; RR 28, labored; BP 104/66; pulse oximetry 59% on room air; respirations labored with use of abdominal accessory muscles; able to speak 3-4 words between breaths; bilevel positive airway pressure (BiPAP) with 40% oxygen (FiO2 ) initiated; intravenous (IV) infusion initiated; blood samples obtained as ordered; need for sputum culture explained to client and spouse. —E. Friche , RN ​ Select the four assessment findings in the EHR that indicate Mr. Smythe is at risk for acute respiratory failure (ARF). Drag and drop each item to the right column. Assessment Findings Indicate Possible ARF Pneumonia​ Worsening shortness of breath​ T 99 °F (37.8 °C)​ BP 106/66​ Productive cough​ Altered mental status​ Blood samples obtained​ Pulse oximetry 59% on room air​
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HEALTH SCIENCE
NURSING

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