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Evaluate Outcomes Review the electronic health record and answer the question that follows. Progress Notes Nurses’ Notes Laboratory Results Date/Time ​ Provider Progress Notes ​ 11/22/20XX ​ 0845 ​ Chief Complaint: headache, dizziness, dyspnea with cough ​ History of Present Illness: Nae Iglesias (pronouns she/her/hers) is a 72-year-old female who presents with complaints of headache, dizziness, dyspnea, and a productive cough. Diagnosed with sinusitis 3 days ago. Vaccinations are not up to date. Nae lives with her daughter and reports increased confusion over the last 24 hours. Medications: Multivitamin, metoprolol, atorvastatin, calcium carbonate, salmeterol/fluticasone meter-dose inhaler (MDI), albuterol nebulizer PRN. Continuous oxygen 2-4L NC at home PRN, decongestant PRN for nasal congestion Past Medical History: COPD, hypertension (HTN), osteoporosis, hypercholesteremia, Type 2 Diabetes Mellitus ​ Review of Systems: ​ General: Clean, well-groomed appearance ​ Neurological: Alert and oriented to person only, confused ​ Cardiovascular: Tachycardic. S1 and S2 are present, and the capillary refill is less than 3 seconds. ​ Respiratory: Respirations shallow and rapid at rest; inspiratory crackles ​ Gastrointestinal: Reports regular, daily bowel movements. Denies abdominal pain ​ Genitourinary: Denies any GI symptoms ​ Musculoskeletal: Denies any pain. Ambulates unassisted. ​ Integumentary: Bluish tint to lips and fingers, skin warm and dry. ​ Allergies: None reported ​ Social History: Retired; lives with daughter; previous 2-pack per day smoker of cigarettes; quit 3 years ago. Daughter smokes in the home. ​ Family History: No significant family history was reported ​ Vital Signs: Temperature: 101.4 °F (38.6 °C); Heart rate: 102 bpm; Respiratory rate: 32 breaths per minute; Blood pressure: 136/84 mmHg; Pulse oximetry: 86% on 2LNC ​ Date/Time Nurses’ Notes 11/22/20XX 0930 The client is admitted to the medical-surgical unit for exacerbation of COPD and pneumonia. Multiple infiltrates noted on chest X-ray. The client is spitting in tissue with greenish-yellow sputum noted. Vitals taken upon admission: Blood pressure is 130/58, pulse is 110, respiration is 32, and SpO2 is 87% on room air. 11/22/20XX 1030 Client reports new onset of nausea, itching, raised rash to face, neck, and anterior chest. Arterial Blood Gas Results pH 7.48 PaCO2 28 HCO3 ‾ 22 PO 85 O2 saturation 95% For each finding, specify if the finding indicates the client’s condition has improved, not changed, or declined. Each finding will match one condition. Improved No Change Declined Alert and oriented to person, place, time, and situation (A&O x4) Expiratory wheezes, no audible crackles, denies shortness of breath Client states, “I need to get my vaccines up to date.” BP 132/56, P 89, R 22, SpO2 95% on 2L NC Temperature 100.2.°F (37.8 °C) Skin with raised rash to face, neck, and anterior chest; reports pruritis
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