Reference no: EM133876366

Question

The nurse is caring for a 72 year old female with history of alcohol use disorder and cirrhosis admitted to the medical-surgical unit. Nurses Notes Vital Signs Medications Laboratory Values Orders Day 1 09:00 Admitted with ascites and confusion, disoriented to person, place and time. History of 29 year alcohol use disorder, hypertension, coronary artery disease, and gastroesophageal reflux disease. Client is lethargic, dyspneic and thin. Peripheral edema noted. Oxygen at 2L per nasal cannula initialed. Daughter at bed side states that client drinks 12-18 beers per day. 14:00 Client is lethargic, moaning occasionally. Mild hand flapping noted. Increased dyspnea with crackles in the bilateral bases. Provider notified. 18:00 Pulse oximetry 95% on 5L NC. Two doses of lactulose administered, 2 large loose bowel movements since first administration. Patient is easily aroused and alert to person and time. Day 2 07:00 Pulse oximeter 96% on room air, lungs diminished, denies shortness of breath. Alert and oriented. Morning ammonia level 71 mcg/dL. Stimulus: 6 of 6 For each assessment finding, indicate if the clients status has improved, declined or has had no change. Finding Improved Declined No Change Oxygen status Lung sounds Abdominal girth Temperature Neuro status Heart rate.