Passage / Scenario

Vital Signs
ÔÇó Heart rate 115/min
ÔÇó Respiratory rate 20/min
ÔÇó BP 90/65 mm Hg
ÔÇó Temperature 38.6┬░C (101.5┬░F)

NursesÔÇÖ Notes
0800:
Client is 3 days postoperative. Currently disoriented to time and place, oriented to self. Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times. Client attempts to get out of bed without assistance. Changes in clientÔÇÖs behavior began the prior evening and client has been awake most of the night. Client has refused to eat or drink since the previous day.
Intake and output from previous day: 250 mL intake, 2,500 mL output.
Call placed to provider to report findings.
0830:
IV fluids initiated by RN. Urine and blood samples collected per providerÔÇÖs prescription. Client continues to be restless.