1857 39-year-old male patient presents in the

1857 39-year-old male patient presents in the progressive unit with a diagnosis of respiratory distress. Vital signs are as follows: P 87, RR 15, BP 124/52, O2 sat 92% on room air, Temp 37, Pain 7/10. The patient’s EKG shows a normal sinus rhythm with occasional ectopy with movement. Head-to-toe assessment is as follows: neurologically oriented 4/4, PERLLA, respirations even and unlabored, clear breath sounds with incentive spirometer exercises measuring 1200mls, cardiac S1 and S2 heard, bowel sounds in all 4 quadrants, urine output in urinal measuring 800mls of clear urine, controlled movement in all 4 extremities, patient has been hesitant to get out of bed. Skin is warm and pink, edema noted on right leg with a hot red patch of skin in right popliteal fossa. 18 gauge IV in left AC that has been flushed with good blood return. Patient took all medications with water, nurse did not suspect aspiration. 2021 Patient becomes agitated and starts kicking off the sheets. Vital signs are as follows: P 105, RR 18, BP 118/48, O2 95% on room air, Temp 37, pain 8/10. Patient states “I don’t know what’s wrong, I just want to go home”. The nurse notices the changes from 1857 to 2021. They begin to make a plan of care for the patient. Which interventions would be indicated? Potential Intervention Indicated Contraindicated Keep in supine position Place Foley catheter Give client oxygen through nasal cannula Print EKG strip to evaluate with MD Call physician for emergency intubation Drag an X to indicate that the intervention would be indicated / contraindicated. Drag a – to indicate that cell should be left blank.

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