📋 Patient Demographics

Patient NameM.C. (initials only) Age / Sex Date of Birth09/22/1963 MRNSIM-02142026 Admit Date/Time02/14/2026 — 1347 Unit / Room4-North Med-Surg / Room 412 AttendingDr. R. Okafor, MD Admitting DxPneumonia — Community Acquired (CAP) Code StatusFull Code ReligionCatholic — advance directive on file Emergency ContactD. Chen (spouse) — 951-555-0147 InsuranceBlueCross PPO — verified

📋 History of Present Illness

Chief Complaint: Worsening cough, fever, and shortness of breath ×4 days.

M.C. is a -year-old male with a history of Type 2 Diabetes Mellitus (T2DM), hypertension (HTN), and obesity (BMI 31.4) who presented to the ED via private vehicle on 02/14/2026 at 1215 with a 4-day history of productive cough with yellow-green sputum, subjective fever (measured at home as 39.2°C), progressive dyspnea on exertion, and pleuritic chest pain on the right. He reports decreased appetite and PO intake for 2 days. Denies sick contacts, recent travel, or known TB exposure. Works as a high school PE teacher. Lives with spouse and two adult children. Non-smoker. Occasional alcohol use (1–2 drinks/week). No illicit drug use.

ED course: CXR confirmed right lower lobe consolidation. SpO₂ 88% on room air on arrival, improved to 95% on 3L NC. IV access obtained, blood cultures ×2 drawn before antibiotics. Admitted to 4-North for IV antibiotics and monitoring.

⚠ Allergies & Adverse Reactions

⚠

PENICILLIN

Reaction: Anaphylaxis — Severity: Severe
Do NOT administer penicillins, ampicillin, amoxicillin, or piperacillin without allergy consult.

⚠

CODEINE

Reaction: Nausea/Vomiting — Severity: Moderate

📋 Past Medical & Surgical History

Past Medical History (PMH)

T2DMDiagnosed 2018 HypertensionDiagnosed 2015 ObesityBMI 31.4 GERDChronic Sleep Apnea (OSA)CPAP dependent — not brought to hospital HyperlipidemiaDiagnosed 2019

Past Surgical History (PSH)

Appendectomy2001 — laparoscopic Right knee scope2019 — arthroscopic

👥 Social History

OccupationHigh school PE teacher TobaccoNever smoker AlcoholOccasional — 1–2 drinks/week Illicit drugsDenies Living situationHome with spouse + 2 adult children Exercise baselineDaily moderate activity (PE teacher) DietLow-sodium, diabetic-friendly per patient report ImmunizationInfluenza — declined this season. Pneumococcal — no record.

🔎 Review of Systems (ROS)

ConstitutionalFever, chills, fatigue, anorexia ×4 days RespiratoryProductive cough (yellow-green), dyspnea, pleuritic right CP CardiovascularNo palpitations, no lower extremity edema GIDecreased appetite, nausea ×1 day, decreased PO ×2 days GUNo dysuria, no hematuria, no frequency NeuroAOx4, no headache, no focal deficits MusculoskeletalDiffuse myalgias SkinNo rash, no lesions

📈 Vital Signs

Date / Time	Temp	HR	RR	BP / MAP	SpO₂ / O₂ Device	Pain	Initials
02/14 1347 (Admit)	38.6°C Oral	104	22	148/92 — MAP 111	92% / 3L NC	4/10	JR
02/14 1700	36.9°C	108	20	152/94 — MAP 113	94%	5/10	JR
02/14 2100	39.4°C Oral	116	24	158/98 — MAP 118	93% / 3L NC	6	JR
02/15 0300	39.8°C Oral	122	26	162/102 — MAP 122	91% / 3L NC	7/10	TN
02/15 0700	39.6°C Oral	118	24	160/100 — MAP 120	91% / 3L NC	6/10	TN

ⓘ Ht: 5′10″ · Wt: 98 kg · BMI: 31.4 · Q4H VS per med-surg protocol

🔬 Laboratory Results — Collected 02/14/2026 1410

Test	Reference Range	Result	Flag	Clinical Significance
HEMATOLOGY — CBC with Differential
WBC	4.5–10.7 ×10³/uL	14.2	H	Leukocytosis — active bacterial infection
RBC	4.50–5.90 ×MIL/uL	4.80	WNL
Hemoglobin	13.5–17.5 g/dL	13.8	WNL
Hematocrit	41–53%	42	WNL
MCV	81–99 fL	89	WNL
Platelets	130–400 ×10³/uL	298	WNL
Neutrophils %	54.0–70.0%	84.3	H	Left shift — bacterial infection
Bands	0–5%	9	H	Bandemia — severe infection
Lymphocytes %	30.0–45.0%	9.8	L	Relative lymphopenia
CHEMISTRY — BMP
Sodium (Na¹)	136–144 mmol/L	138	WNL
Potassium (K¹)	3.6–5.1 mmol/L	3.4	L	Mild hypokalemia — decreased PO intake; monitor for dysrhythmia
Chloride (Cl−)	101–111 mmol/L	103	WNL
CO₂ (Bicarb)	22–32 mmol/L	23	WNL
BUN	8–26 mg/dL	24	WNL	High-normal — mild dehydration from decreased PO
Creatinine	0.7–1.2 mg/dL	1.1	WNL
eGFR (MDRD)	>60	74	WNL
Glucose (admit)	70–110 mg/dL	187	H	Stress hyperglycemia + T2DM. Metformin held per protocol.
Glucose (fasting 0600)	70–110 mg/dL	214	H	Poorly controlled in setting of acute infection
INFLAMMATORY MARKERS
C-Reactive Protein (CRP)	<1.0 mg/dL	18.4	HH ‼	Severely elevated — significant acute bacterial inflammation
Procalcitonin (PCT)	<0.5 ng/mL	2.8	H	Strongly suggests bacterial etiology; guides antibiotic use and duration
ESR	0–20 mm/hr (M)	68	H	Elevated — consistent with acute infection
MICROBIOLOGY
Blood Culture ×2	No growth	PENDING	⌛	Drawn before antibiotics ✓ — 48–72 hr turnaround
Sputum Gram Stain	Normal flora	Gram (+) cocci in pairs	H ‼	Consistent with Streptococcus pneumoniae — speciation and sensitivities pending
MRSA Nasal Swab	Negative	Negative ✓	WNL	Collected 02/14 1415 — resulted 02/14 2240. No MRSA colonization detected.
Sputum C&S	Normal flora	PENDING	⌛	Empiric Vancomycin covers MRSA pending sensitivities
Legionella Urine Ag	Negative	Negative ✓	WNL	Pertinent negative — Legionella excluded

🚨 IV Antibiotics — Active

⚠

ALLERGY ON FILE: PENICILLIN (ANAPHYLAXIS)

Verify all antibiotics against allergy record before administration. Vancomycin and Azithromycin are confirmed allergy-safe alternatives.

Drug	Dose / Route / Frequency	Indication	Last Given	Next Due	Status
Vancomycin 1,250 mg IV — weight-based (12.75 mg/kg) Run over 90 min. Trough draw ordered before dose 3.	1,250 mg IV Q12H	CAP — empiric coverage pending sputum C&S; Gram(+) cocci on sputum GS	02/14 1600	02/15 0400	Active
Azithromycin Atypical coverage — allergy-safe ✓	500 mg IV daily ×5 days	CAP — atypical coverage (Mycoplasma, Chlamydia)	02/14 1530	02/15 1530	Active

📋 Scheduled Medications

Drug	Dose / Route / Frequency	Indication	Last Given	Next Due	Status
Acetaminophen (Tylenol) 650 mg PO — PRN fever/pain — Max: 3,900 mg/24hr	650 mg PO Q6H PRN	Fever management / pain	02/14 2230	02/15 0430	Available PRN
Lisinopril ACE Inhibitor	10 mg PO daily	Hypertension	02/14 1400	02/15 1400	Active
Hydrochlorothiazide (HCTZ) Thiazide Diuretic	25 mg PO daily	Hypertension / volume	02/14 1400	02/15 1400	Active
Atorvastatin (Lipitor) Statin	40 mg PO nightly	Hyperlipidemia	02/14 2100	02/15 2100	Active
Omeprazole (Prilosec) PPI	20 mg PO daily AC	GERD / stress ulcer prophylaxis	02/14 1400	02/15 1400	Active
Metformin (Glucophage) Home med — held inpatient	1,000 mg PO BID — HOME MED	T2DM	—	—	HELD
Insulin Glargine (Lantus) Added inpatient — basal coverage	10 units SQ every evening	T2DM — inpatient glycemic control	02/14 2100	02/15 2100	Active
Insulin Lispro (Humalog) Sliding scale AC + HS	BG <150: 0u \| 151–200: 2u \| 201–250: 4u \| 251–300: 6u \| >300: notify MD	Stress hyperglycemia	02/14 1730 — 4u (BG 214)	02/15 0600	Active

💊 PRN Medications

Drug	Dose / Route / Indication	Times Given	Status
Ondansetron (Zofran)	4 mg IV Q6H PRN nausea	02/14 1530	Available
Albuterol MDI	2 puffs Q4H PRN bronchospasm	02/14 1600, 2200	Available

📜 Medication Reconciliation Note: Patient reported taking NyQuil at home for symptom management. OTC medication reconciliation in progress — contents not yet reviewed against current MAR. See admitting note.

📋 Active & Completed Orders — Dr. R. Okafor, MD

#	Date/Time	Order	Category	Status
1	02/14 1400	Continuous Pulse Oximetry — alarm SpO₂ <90%	Monitoring	Active
2	02/14 1400	Vital Signs Q4H	Monitoring	Active
3	02/14 1400	Telemetry — continuous cardiac rhythm monitoring	Monitoring	Active
4	02/14 1400	Oxygen Therapy — 3L/min NC; titrate to SpO₂ 92–96%; if SpO₂ <90% increase to 5L and notify provider STAT	Respiratory	Active
5	02/14 1400	IV Access — 20G PIV Left Forearm — flush Q8H; site assessment Q8H; change Q72H	IV Access	Active
6	02/14 1400	D5½NS at 75 mL/hr — maintenance IV; reassess daily	Fluids	Active
7	02/14 1400	Blood Cultures ×2 — bilateral venipuncture before first antibiotic dose	Microbiology	Complete
8	02/14 1400	Sputum Gram Stain + C&S — deep cough sample before antibiotics	Microbiology	Complete
9	02/14 1400	Vancomycin 1,250 mg IV Q12H — start 02/14 1600; draw trough 30 min before dose 3; HOLD dose 3 until trough results received	Medication	Active
10	02/14 1400	Azithromycin 500 mg IV daily ×5 days	Medication	Active
11	02/14 1400	Strict I&O — Q8H totals + PRN	Nursing	Active
12	02/14 1400	Foley Catheter — accurate I&O; document insertion date/time; Foley care Q8H; reassess necessity daily	Procedure	Active
13	02/14 1400	Blood Glucose Monitoring — AC & HS; sliding scale Lispro; notify MD for BG <70 or >300	Monitoring	Active
14	02/14 1400	Vancomycin Trough Contingency IF trough <10 mcg/mL → increase to 1,500 mg IV Q12H; notify pharmacy for AUC monitoring. IF trough 10–20 mcg/mL → maintain 1,250 mg Q12H. IF trough >20 mcg/mL → HOLD next dose; notify provider + pharmacy; repeat trough in 6 hrs.	Contingency	Pending Trough
15	02/14 1400	High Fall Risk Precautions — bed lowest, bed alarm, call light in reach, grip socks	Safety	Active
16	02/14 1400	Diet: Regular / Diabetic-Friendly / Low-Sodium — encourage PO fluids	Diet	Active

ⓘ Active = ongoing | Complete = executed | Pending = awaiting action or results

💧 Intake Log — 02/14 1347 → 02/15 0700

Time	Type	Amount (mL)	By
1400	D5½NS IV @ 75 mL/hr (x2hr)	150	JR
1500	PO — Water	120	JR
1600	Vancomycin 1,250 mg in 250 mL NS IV	250	JR
1600–1800	D5½NS IV @ 75 mL/hr	150	JR
1800	Dinner tray — broth, juice, water	240	JR
2200	PO — Water	90	TN
2200–0200	D5½NS IV @ 75 mL/hr	300	TN
0200–0700	D5½NS IV @ 75 mL/hr	375	TN

Documented Intake Total: 1,675 mL

💧 Output Log — 02/14 1347 → 02/15 0700

Time	Type	Amount (mL)	By
1500	Foley — Urine (yellow, clear)	180	JR
1900	Foley — Urine (yellow, clear)	150	JR
2100	Foley — Urine (yellow, amber)	110	JR
0300	Emesis — yellow-brown	75	TN
0500	Foley — Urine (yellow, concentrated)	95	TN
0700	Foley — Urine (yellow)	80	TN

Documented Output Total: 690 mL

ⓘ Foley inserted 02/14 1430. Foley care due Q8H. Next site rotation: PIV 20G L forearm inserted 02/14 1400, due 02/17 1400.

📝 Clinical Notes — Newest first

RN Note End-of-Shift SBAR / Handoff 02/15/2026 0700 — T. Nguyen, RN, BSN | Signed: 02/15 0714

S — Situation: M.C. is a 62-year-old male admitted 02/14 for community-acquired pneumonia with right lower lobe consolidation. He remains febrile and his respiratory status has declined overnight. He is currently on 3L NC with SpO₂ 91%, and his fever has continued to rise through the night despite Vancomycin and Azithromycin. This patient has not improved as expected and will need close monitoring this shift.

B — Background: PMH includes T2DM, HTN, obesity (BMI 31.4), OSA (CPAP not at bedside), GERD, and hyperlipidemia. Allergies: Penicillin (anaphylaxis) and Codeine (nausea/vomiting). Sputum Gram stain grew Gram-positive cocci in clusters — MRSA not yet confirmed; C&S pending. Blood cultures ×2 pending. Vancomycin dose 1 given 1600; dose 2 on hold — trough drawn 0330, result still pending at time of report.

A — Assessment: Temp 39.6°C at 0700, HR 118, RR 24, BP 160/100, SpO₂ 91% on 3L NC. Breath sounds diminished RLL, unchanged. Patient anxious but AOx4. Foley draining amber concentrated urine — UO trending lower overnight. Glucose 214 at 1730; Lantus given. BG not rechecked overnight per patient refusal at 0200; declined verbally, documented. IV site patent. Foley care completed 0600.

R — Recommendation: Await Vancomycin trough result — do not administer dose 2 until confirmed. If SpO₂ drops below 90%, escalate to 5L per existing order and notify Dr. Okafor. Provider aware of overnight deterioration — progress note placed at 0630. Encourage PO fluids. Morning BG check due at breakfast. Watch for blood culture results — call provider immediately with any organism ID.

RN Note Night Assessment 02/15/2026 0500 — T. Nguyen, RN, BSN | Signed: 02/15 0512

Respiratory: SpO₂ 91% on 3L NC. RR 24. Breath sounds diminished RLL — unchanged from 0115 assessment. Cough productive. Incentive spirometry encouraged; patient completed 3 attempts, reaching 600 mL. Pleuritic chest pain 6/10 limiting deep inspiration. Albuterol MDI ×2 puffs given at 0445 with mild improvement in wheezing; SpO₂ unchanged.

Vancomycin Trough: Trough specimen drawn 0330 as ordered. Lab confirmed receipt. Result pending. Dose 2 (originally due 0400) remains on hold. Patient verbalized understanding of hold rationale.

Glycemic: Patient declined bedtime BG check at 0200 — stated "I don't want any more pokes tonight." Educated on importance of monitoring. Will attempt again at 0600 before day shift. Lantus 10 units given 2100 as ordered.

I&O: Foley draining concentrated amber urine. Output 95 mL at 0500. IV fluids D5½NS running at 75 mL/hr — bag changed 0300. Encouraged PO water — patient sipped approximately 60 mL.

Comfort: Positioned in semi-Fowler's. Fan at bedside for diaphoresis. Tepid cloth applied to forehead at 0400 for comfort. Patient resting between assessments but waking frequently with cough.

RN Note Trough Draw / Medication Hold 02/15/2026 0330 — T. Nguyen, RN, BSN | Signed: 02/15 0338

Vancomycin trough drawn via venipuncture right antecubital at 0330 — 30 minutes before scheduled dose 2 at 0400, per Order #9. Specimen labeled and sent to laboratory. Lab tech confirmed receipt at 0342.

Vancomycin dose 2 (1,250 mg IV) placed on hold pending trough result per contingency Order #14. Pharmacy notified at 0335 — pharmacist T. Park acknowledged hold and will call with result when available.

Patient informed of hold and rationale — patient verbalized understanding.

RN Note Provider Notification 02/15/2026 0115 — T. Nguyen, RN, BSN | Signed: 02/15 0128

0100 VS: Temp 39.8°C Oral | HR 122 | RR 26 | BP 162/102 | SpO₂ 91% on 3L NC. All values worsening compared to 2100 set.

Respiratory: Breath sounds diminished RLL. Albuterol MDI ×2 puffs given at 0030 — minimal bronchodilator effect. SpO₂ returned to 91% within 10 minutes.

Provider notification: Dr. Okafor called at 0110 via hospital operator. Reported worsening respiratory status, persistent fever 39.8°C, HR 122, SpO₂ 91% on 3L NC. Dr. Okafor acknowledged — instructed to continue current orders, escalate O₂ to 5L if SpO₂ drops below 90%, and place morning progress note. Will round at 0630. No new orders received at this time.

Patient: Anxious, asking why fever is not breaking. Reassurance provided. Spouse called by patient at 0130 per patient request — patient updated family independently.

Provider Note Evening Update 02/14/2026 2000 — Dr. R. Okafor, MD | Signed: 02/14 2012

Status: Persistent fever despite initial antibiotic doses. Expected clinical response within 48–72 hours of antibiotic initiation. Continued monitoring appropriate. Await culture results to guide de-escalation or targeted therapy.

Glycemic: Glucose 214 at 1730. Lantus 10 units administered. Sliding scale to continue. Target BG 140–180 per ADA inpatient guidelines.

Respiratory: SpO₂ 93–94% on 3L NC — acceptable. Contingency order in place if SpO₂ drops below 90%.

Plan: Continue current antibiotic regimen. Vancomycin trough before dose 2. Reassess at morning rounds.

RN Note Evening Assessment 1800 — J. Rivera | Signed: 1812

Patient c/o chest pain 5/10 and SOB. SpO₂ 93% on 3L NC. HR 116. Albuterol administered ×2 puffs with mild improvement in breath sounds. Temp 39.4°C. Acetaminophen 650 mg PO administered for fever and discomfort.

Patient sleeping comfortably when last assessed. Family present at bedside. No further complaints noted at time of documentation.

Vancomycin infusion running — approximately 1 hour 20 minutes remaining. IV site left forearm patent, no redness or swelling noted. Foley draining appropriately.

Gown and gloves donned prior to room entry per isolation precautions.

RN Note Admission 1347 — J. Rivera, RN, BSN | Signed: 02/14 1402

Time of Admission: 1347. Patient received from ED via transport. Alert and oriented ×4. Ambulating with steady gait to room. 20G PIV placed left forearm — patent, infusing without difficulty.

Initial Vital Signs: See Vitals panel. SpO₂ 92% on 3L NC (was 88% on room air in ED). Pleuritic chest pain 4/10 on inspiration, right lateral.

Allergies Confirmed: Penicillin (anaphylaxis), Codeine (nausea/vomiting) — allergy armband placed and verified with patient verbally.

Physician Notification: Dr. Okafor notified of admission at 1355. Orders received and transcribed. Vancomycin and Azithromycin initiated.

Isolation precaution sign placed on room door. Gown and gloves available outside room 412.

Patient Reports: Taking NyQuil at home for cough and fever control ×3 days prior to admission. OTC medication reconciliation initiated — pending pharmacy review.

🔍 Assessment 1 — 02/14/2026 1400 — J. Rivera, RN

🧠 Neuro / Mental Status

Patient awake and talking. Follows commands. Oriented.

🮺 Respiratory

SpO₂ 92% on 3L NC. RR 22. Breath sounds diminished on the right. Cough present with yellow sputum. Chest pain with breathing.

❤️ Cardiovascular

HR 104. BP 148/92. Heart sounds normal. Some swelling in ankles.

😋 GI / Abdomen

Bowel sounds present. Abdomen soft. Nausea earlier, Zofran given.

💧 GU / Renal

Foley draining yellow urine.

🧣 Skin / Integumentary

Skin warm. IV site intact. No redness noted.

🦸️ Musculoskeletal

Ambulatory. Moving all extremities.

🔍 Assessment 2 — 02/15/2026 0115 — T. Nguyen, RN, BSN

🧠 Neuro / Mental Status

GCS 15 (E4 V5 M6). Alert and oriented ×4 — person, place, time, event. Pupils 3 mm bilaterally, equal and reactive to light (PERRL). Facial symmetry intact — no drooping, no asymmetry. Grip strength 4/5 bilaterally, equal. Pedal pushes 4/5 bilaterally. No reported headache, vision changes, or numbness. Denies dizziness. Anxious affect appropriate to situation — asking questions about illness trajectory. No focal neurological deficits.
Nursing relevance: Neuro assessment critical given rising fever (39.8°C) and worsening tachycardia — hypoxia and sepsis can cause altered mental status. Baseline AOx4 is a critical comparative reference point. Any change from this baseline requires immediate provider notification.

🮺 Respiratory

RR 26, labored. Increased work of breathing noted — mild accessory muscle use. Chest rise equal bilaterally. SpO₂ 91% on 3L NC — declining from 92–94% documented earlier this shift. Lung sounds: clear upper lobes bilaterally; clear left lower lobe; right lower lobe: diminished with dullness to percussion — consolidation consistent with admitting diagnosis. Vocal fremitus increased over RLL. Productive cough — moderate amounts yellow-green sputum. Pleuritic right chest pain 7/10 with inspiration; patient self-limiting deep breathing. Albuterol MDI ×2 puffs given 0030 with minimal bronchodilator response.
Nursing relevance: RLL consolidation reduces effective gas exchange surface area. Increasing respiratory rate with declining SpO₂ despite 3L NC indicates progressive respiratory compromise. If SpO₂ drops below 90%, escalate O₂ to 5L per active order and notify provider STAT. Incentive spirometry compromised by pain — pain management must be optimized to allow adequate tidal volume.

❤️ Cardiovascular

HR 122, regular sinus tachycardia (confirmed on telemetry). BP 162/102, MAP 122. S1 and S2 present and distinct. No murmurs, rubs, or gallops auscultated. No S3 or S4. Peripheral pulses 2+ bilaterally — radial, dorsalis pedis. Capillary refill <2 sec bilaterally. Skin warm, diaphoretic. No JVD. +1 bilateral lower extremity edema to ankles — patient reports this is his baseline since approximately 2023.
Nursing relevance: Sinus tachycardia expected with fever 39.8°C and systemic infection — however, HR 122 with BP 162/102 despite Lisinopril on board indicates systemic inflammatory response. MAP 122 — well above perfusion threshold of 65 at this time. K+ 3.4 (mild hypokalemia) + tachycardia = dysrhythmia risk; continuous telemetry monitoring essential. Tachycardia resolves target: HR <100 as fever and infection are treated.

😋 GI / Abdomen

Abdomen soft, round, non-tender, non-distended. Bowel sounds present and normoactive in all four quadrants. No guarding, no rebound tenderness. No palpable masses or organomegaly. Emesis episode 0300: 75 mL yellow-brown liquid; Zofran administered with relief. Appetite markedly decreased — approximately 30–40% of dinner tray consumed. Decreased PO intake ×2 days per history. Last bowel movement: 02/13 at home, patient reports normal consistency and effort.
Nursing relevance: Decreased PO intake → mild dehydration (BUN 24, high-normal) → concentrated urine (amber, Foley). Nutritional status concerns in setting of hypermetabolic state from fever and infection. Monitor albumin trend. Ensure IV maintenance fluids running at ordered rate.

💧 GU / Renal

Foley catheter in place since 02/14 1430 — 16Fr, balloon 10 mL, draining freely. Urine color: amber-yellow, slightly concentrated. No cloudiness, no odor. Foley tubing positioned below bladder level, no kinks. Foley care due Q8H — next documentation due 02/14 2230 (8-hr post-insertion mark). Output: 95 mL at 0500, 80 mL at 0700 — monitoring for adequate UO (minimum 0.5 mL/kg/hr = ~49 mL/hr for this patient). Current rate trending lower than minimum. eGFR 74 — adequate renal function; however, Vancomycin is nephrotoxic and trough monitoring is essential.
Nursing relevance: Decreased UO + concentrated urine = inadequate fluid intake and/or infection-related renal vasoconstriction. Vancomycin trough pending — nephrotoxicity risk. CAUTI prevention: daily necessity assessment, maintain closed drainage system, Foley care Q8H per order. Goal: discontinue Foley as soon as accurate UO measurement can be obtained by voiding.

🧣 Skin / Integumentary

Braden Scale: 18 (Low Risk). Skin warm and diaphoretic throughout — fever-related. Skin intact — no breaks, no wounds, no rashes, no bruising. Bony prominences: coccyx, heels, and sacrum intact without erythema. IV site left forearm 20G: no redness, swelling, warmth, or phlebitis. Site patent — flushes freely, infusing without resistance. IV site assessment Q8H per order. Mucous membranes mildly dry — encourage PO fluids. Skin turgor normal. No lower extremity skin color changes or temperature differential noted.
Nursing relevance: Diaphoresis + decreased mobility due to illness = increased moisture and friction risk. Although Braden 18 is low risk, fever, obesity (BMI 31.4), and diaphoresis require ongoing monitoring. IV site integrity critical for antibiotic delivery — any infiltration would interrupt Vancomycin infusion.

🦸️ Musculoskeletal

Full active range of motion in all extremities. Grip strength 4/5 bilaterally — limited by fatigue and mild myalgias (patient-reported diffuse muscle aching). Pedal pushes equal and 4/5 bilaterally. Independent ambulator at baseline — in-hospital activity limited by dyspnea and pleuritic pain. Currently on bed rest with bathroom privileges and fall precautions. Grip socks in place. Call light in reach. Bed in lowest position with alarm active.
Nursing relevance: Fever (39.8°C), tachycardia (HR 122), and deconditioning from illness → orthostatic hypotension risk with ambulation. Activity level should be gradually increased as fever resolves. SCDs ordered — verify application and functioning.

📋 Physician Progress Notes — Dr. R. Okafor, MD

02/15/2026 0630 — Dr. R. Okafor, MD — Attending Progress Note

Subjective: Patient with persistent fever and worsening respiratory status overnight. Anxious but conversational. Denies new symptoms.

#1 — Community-Acquired Pneumonia (CAP) / Possible MRSA / Gram-Positive Pneumonia

Assessment: RLL consolidation on CXR. Sputum Gram stain: Gram(+) cocci in clusters. Cultures pending. WBC 14.2 with bandemia. Procalcitonin 2.8 — consistent with bacterial etiology. Fever 39.8°C at 0300 — not yet responding to antibiotics (expected 48–72 hr window).
Plan: Continue Vancomycin and Azithromycin. Vancomycin trough pending — adjust dose per contingency order. Await C&S results for de-escalation or targeted therapy. If no clinical improvement by 02/16 0600, consider ID consult and broadening coverage.

#2 — Hypoxemic Respiratory Insufficiency

Assessment: SpO₂ 91% on 3L NC — declining. RR 26. Albuterol with minimal response. No CPAP in hospital (home device not available).
Plan: Maintain 3L NC; if SpO₂ <90%, escalate to 5L or high-flow face mask per nursing order. Respiratory therapy consult if worsening. Repeat CXR ordered for 02/15 AM to assess interval change. If no improvement by afternoon, consider step-up level of care.

#3 — Type 2 Diabetes Mellitus — Inpatient Glycemic Management

Assessment: Glucose 214 at 1730. Stress hyperglycemia expected with active infection. Lantus 10u + sliding scale Lispro in place. Metformin appropriately held.
Plan: Continue current insulin regimen. Target BG 140–180. Check fasting glucose 0600 — result pending. Reassess insulin dose if BG consistently above target.

#4 — Hypertension — Suboptimally Controlled in Setting of Infection

Assessment: BP 162/102 at 0300 despite Lisinopril and HCTZ on board. Infection-driven sympathetic activation likely contributing. No end-organ damage signs at this time.
Plan: Continue home antihypertensives. No acute antihypertensive intervention at this time. Monitor closely — if BP >180/110 or symptoms develop, notify provider for PRN order consideration.

#5 — Vancomycin Nephrotoxicity Monitoring

Assessment: eGFR 74 (baseline adequate). Vancomycin dose 1 given 02/14 1600. Trough drawn before dose 3 per protocol. Dose 3 on hold pending result.
Plan: Pharmacist notified for AUC-guided dosing review. BMP Q24H for renal function trending while on Vancomycin. Adjust dose per trough and pharmacist recommendation.

🎓 Patient & Family Education — Teach-Back Documentation

Teach-Back 1 Incentive Spirometry — Purpose and Technique — 02/14 1500 | J. Rivera, RN

Topic: Purpose of incentive spirometry in pneumonia recovery; correct technique including slow deep breath with 10-second hold.

Return Demonstration: Patient demonstrated technique ×2 after coaching. Sustained inspiration to 750 mL. Technique adequate.

Patient verbalized: “I use this to keep my lungs from collapsing and help clear the secretions out.” ✓ Goal met.

Barrier identified: Pleuritic pain limits deep inspiration. Pain management optimized prior to therapy sessions.

Teach-Back 2 Vancomycin Trough — Why Next Dose Is on Hold — 02/14 2200 | T. Nguyen, RN, BSN

Topic: Purpose of blood level (trough) monitoring; kidney protection rationale; safety of intentional dose hold.

Patient verbalized: “They want to make sure the medicine isn’t building up too much and hurting my kidneys.” ✓ Accurate.

Anxiety addressed: Patient concerned that missing a dose means the infection is untreated. Reassured that one therapeutic hold is safer than nephrotoxic drug accumulation.

Teach-Back 3 OTC Medication Safety — Acetaminophen Double-Dosing Risk — 02/14 1600 | J. Rivera, RN

Topic: Acetaminophen content in NyQuil; risk of exceeding daily maximum when combined with prescribed Tylenol.

Patient verbalized: “I didn’t know NyQuil had Tylenol in it. So I shouldn’t take both.” ✓ Accurate.

Action taken: NyQuil added to medication reconciliation list. Pharmacist notified for MAR review. Provider notified of potential cumulative acetaminophen exposure.