A nurse is caring for a 20-year-old male client who has a fe…
A nurse is caring for a 20-year-old male client who has a fever and reports severe headache.Vital Signs at 0800Temperature 38.9° C (102° F); TympanicApical pulse 118/min; strong and regularRespirations 20/min; even and unlabored Blood pressure 114/78 mm Hg Oxygen saturation 97% on room airNurses Notes0800:Client reports missing classes at a local community college the last two days due to fever and headache. Rates pain with headache as a 9 on a scale of 0 to 10. Verbalizes that headache was not relieved by acetaminophen or ibuprofen taken at home. Client awake, alert, and oriented to person, place, and time. Pupils equal, round, and reactive to light. Temperature elevated. Skin warm and dry, face flushed. Petechiae noted on trunk. Reports nausea and vomiting frequent for the last 24 hr. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present. Nuchal rigidity noted. Brudzinski’s sign positive. Respirations easy and unlabored. Lungs clear to auscultation. 0830: Provider notified of client’s current vital signs and assessment findings. New prescriptions received. Providers Prescription: Prepare for lumbar puncture Draw CBC with differential X-ray: Chest and sinuses 1000 Vital Signs Temperature 38.9° C (102° F); Tympanic Apical pulse 50/min; strong and regular Respirations 10/min; even and unlabored Blood pressure 190/105 mm Hg Oxygen saturation 97% on room air 1000 Nurses notes: Assessment completed after lumbar puncture. Client awake, restless, confused, and oriented to person only. Pupils equal, round, and reactive to light. Temperature elevated. Skin warm and dry, face flushed. Petechiae noted on trunk. Decerebrate posturing noted. Occasional vomiting. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present. Nuchal rigidity noted. Brudzinski’s sign positive. Respirations easy and unlabored. Lungs clear to auscultation. For each assessment finding, click to specify if the finding indicates that the client’s condition has improved, has not changed, or has declined.