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Nurses’ Notes 1455: Client drowsy, disoriented to place and time.
Nurses’ Notes 1455: Client drowsy, disoriented to place and time. Respirations 22/min. Oxygen saturation 94%. Lung sounds with rales noted in bilateral bases. Productive cough noted with yellow sputum. Capillary refill <3 seconds. 1500: Head of bed elevated. Positioned for comfort. Turned to left side. Family at bedside. Mouth care provided. 1545: Client unresponsive to verbal or tactile stimuli. Respirations labored, rate 35/min. Breath sounds with rales bilaterally. Oxygen saturation 79%. Fingers cyanotic. Accessory muscle use noted. Capillary refill 5 seconds. Bowel sounds active all quadrants.
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