The nurse is caring for a client with pneumonia. Click on each tab below to review the electronic
health record (EHR), and answer the question.
Nurses' Notes
Laboratory Results
For each of the clients clinical manifestations below, click to specify if the finding is consistent with
asthma, pneumonia, or heart failure. Each finding may support more than one disease process.
Asthma
Pneumonia
Heart Failure
temperature of 38.9C
inspiratory crackles left lower lung
oxygen saturation 82%
tripod position
white blood cell count of 19,548
respiratory rate (RR) 32
Date/Time NURSES NOTES
A 64-year-old was admitted through the
emergency department with worsening dyspnea
and productive cough over the last 2 days;
recently diagnosed with inoperable lung cancer;
past medical history of atrial fibrillation, heart
failure, Diabetes Mellitus Type 2 (DM2),
hypertension, and dyslipidemia. Vital signs (VS):
T 97.8 F (36.5 C); HR 98 irregularly irregular;
RR 16; BP 136/89; oxygen saturation (O sat)
2
4/4/20XX 03:30 98% on 2 L nasal cannula; inspiratory crackles
in lower left lung fields, clear all other areas;
chest X-ray shows a left basilar infiltrate
consistent with pneumonia; admission
assessment completed; copy of advance
directive and durable power of attorney
documents in electronic health record (EHR);
currently resting with head of bed at 30 angle,
call light in reach, upper siderails raised, and
night light on.
Entered room to find the client sitting in a chair
in tripod position leaning on the side of the bed;
VS: T 102.1 F (38.9 C), HR 142 irregularly
4/4/20XX 06:40
irregular; RR 32 and labored with pursed-lip
exhalation; O sat 82% on room 2 L nasal
2
cannula..
The nurse is caring for a client with pneumonia Click on ea.pdf
1. The nurse is caring for a client with pneumonia. Click on each tab below to review the electronic
health record (EHR), and answer the question.
Nurses' Notes
Laboratory Results
For each of the clients clinical manifestations below, click to specify if the finding is consistent with
asthma, pneumonia, or heart failure. Each finding may support more than one disease process.
Asthma
Pneumonia
Heart Failure
temperature of 38.9C
inspiratory crackles left lower lung
oxygen saturation 82%
tripod position
white blood cell count of 19,548
respiratory rate (RR) 32
Date/Time NURSES NOTES
4/4/20XX 03:30
A 64-year-old was admitted through the
emergency department with worsening dyspnea
and productive cough over the last 2 days;
recently diagnosed with inoperable lung cancer;
past medical history of atrial fibrillation, heart
failure, Diabetes Mellitus Type 2 (DM2),
hypertension, and dyslipidemia. Vital signs (VS):
T 97.8 F (36.5 C); HR 98 irregularly irregular;
RR 16; BP 136/89; oxygen saturation (O
2
sat)
98% on 2 L nasal cannula; inspiratory crackles
in lower left lung fields, clear all other areas;
chest X-ray shows a left basilar infiltrate
consistent with pneumonia; admission
assessment completed; copy of advance
directive and durable power of attorney
documents in electronic health record (EHR);
currently resting with head of bed at 30 angle,
call light in reach, upper siderails raised, and
night light on.
4/4/20XX 06:40
Entered room to find the client sitting in a chair
in tripod position leaning on the side of the bed;
VS: T 102.1 F (38.9 C), HR 142 irregularly
irregular; RR 32 and labored with pursed-lip
exhalation; O
2
sat 82% on room 2 L nasal
cannula.
