Passage / Scenario

Nurses Notes
Provider Prescriptions
Graphic Record
Day 1, 1600:
Client admitted from provider's clinic reporting shortness of breath. dry hacking cough, dizziness, and "heart racing." States they are not able to sleep well on their back at night because of difficulty breathing.
Alert and oriented x3. Pupils equal, round, reactive to light. accommodation at 3 mm. Heart rate 130/min, ECG monitor showing sinus tachycardia, S, auscultated. Lower extremity edema noted, 2+ bilaterally Radial and pedal pulses 1+ bilaterally
Breathing rapid and shallow. Crackles auscultate in bases bilaterally. Bowel sounds normoactive in all four quadrants Reports no difficulty urinating
Client reports gaining 10 pounds in the past month.
Reports history of type 2 diabetes mellitus and hypertension.