1145 Patient HJ is a 87 year

1145 Patient HJ is a 87 year old man who has a diagnosis of altered mental status. He has a Glasgow Coma Scale of 12. Vital signs are as follows. P 86, RR 15, MAP 82, O2 sat 89% on room air, temp 37, pain 1/10. Wife states that “he’s starting to lose it”. HJ has a poor nutritional status and is frequently confused. 1207 The CNA was feeding HJ some oatmeal when he became agitated and started screaming. The call light is going off and you assess your patient. Vital signs are as follows: P 102, RR 20, MAP 110, O2 sat 82%, temp 37, pain 1/10. Patient is red in the face and is gasping. Lung sounds have coarse crackles in all lobes. EKG shows sinus tachycardia. The nurse has completed the orders given by the physician. For each assessment if the client’s condition has improved, declined, or made no change. Client Assessment at 1207 compared to 1145 Improved No Change Declined RR 22 P 102 MAP 110 O2 saturation 82% Temp 37 Drag an X to a cell to mark it. Drag a – to indicate that the cell should be left blank. SCIENCE HEALTH SCIENCE NURSING NURS 4130

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