Nurses' Notes
1025:
The client arrived from home by private vehicle accompanied by the spouse. The client is brought to the emergency department after two days of fever and gastrointestinal illness. The client has taken prednisone daily for autoimmune disease for the past eight months. The spouse reports that the client stopped taking prednisone three days ago because the prescription bottle was empty. The client has had six episodes of vomiting since last night and cannot keep liquids or medication down. Chronic fatigue and gradual weight loss were documented at a clinic visit last month without an acute change. The skin has stable darkening over old scars that has been present for months and has not changed recently. On arrival, the blood pressure is 78/44 mm Hg with a weak peripheral pulse. The pulse is 126 beats per minute, respirations are 24 breaths per minute, and oxygen saturation is 96% on room air. The client answers slowly and reports diffuse weakness. Point-of-care testing shows a blood glucose level of 52 mg/dL. The abdomen is mildly tender without rigidity, guarding, or rebound tenderness. Laboratory results show sodium 124 mEq/L and potassium 5.9 mEq/L. The spouse reports one loose stool this morning. The nurse places the client on continuous monitoring, obtains intravenous access, and alerts the emergency provider.
Nurses' Notes
1025:
The client arrived from home by private vehicle accompanied by the spouse. The client is brought to the emergency department after two days of fever and gastrointestinal illness. The client has taken prednisone daily for autoimmune disease for the past eight months. The spouse reports that the client stopped taking prednisone three days ago because the prescription bottle was empty. The client has had six episodes of vomiting since last night and cannot keep liquids or medication down. Chronic fatigue and gradual weight loss were documented at a clinic visit last month without an acute change. The skin has stable darkening over old scars that has been present for months and has not changed recently. On arrival, the blood pressure is 78/44 mm Hg with a weak peripheral pulse. The pulse is 126 beats per minute, respirations are 24 breaths per minute, and oxygen saturation is 96% on room air. The client answers slowly and reports diffuse weakness. Point-of-care testing shows a blood glucose level of 52 mg/dL. The abdomen is mildly tender without rigidity, guarding, or rebound tenderness. Laboratory results show sodium 124 mEq/L and potassium 5.9 mEq/L. The spouse reports one loose stool this morning. The nurse places the client on continuous monitoring, obtains intravenous access, and alerts the emergency provider.