A nurse is caring for a client who was just admitted from the emergency department (ED).
Nurses' Notes 0945:
The client is most likely experiencing a sickle cell crisis. The client states that they began experiencing pain in the lower extremities 3 days ago and is now experiencing pain in the chest, rating it as 4 on a scale of 0 to 10.
Exhibit 1:
Fluid volume overload
Oxygen at 3 L/min via nasal cannula in place
Acute chest syndrome
Oral mucosa pink, no cyanosis.
Pulses palpable in all four extremities, no peripheral edema noted.
Pneumonia
Respirations even and slightly labored; lung sounds with slight wheezing in left upper lobe.
Pneumothorax
Abdomen soft and nontender, bowel sounds active in all four quadrants.
Right-sided heart failure
0.45% sodium chloride IV at 200 mL/hr infusing to left hand with no reports of pain or swelling at the site
Exhibit 2:
Client is sitting up in high-Fowler's position and appears anxious. Client reports shortness of breath and severe chest pain as 9 on a scale of 0 to 10. Client states that they have started coughing and are expectorating pink-tinged mucus.
Lung sounds with increased wheezing in left lung and clear on the right side. Equal chest expansion noted. Neck veins flat. No peripheral edema observed.