0115 — T. Nguyen, RN, BSN, performed a complete head-to-toe assessment on M.C. as part of routine night-shift care.

Patient found awake in bed, GCS 15 (E4 V5 M6), alert and oriented ×4 to person, place, time, and event. Pupils 3mm bilaterally, equal and reactive to light. Facial symmetry intact, no drooping or asymmetry noted. Grip strength 4/5 bilaterally and equal; pedal pushes 4/5 bilaterally. Patient denies headache, vision changes, numbness, or dizziness. Affect anxious but appropriate to situation — patient asking questions about his illness trajectory. No focal neurological deficits noted.

Respirations 26 per minute and labored, with mild accessory muscle use observed. Chest rise equal bilaterally. SpO₂ 91% on 3L nasal cannula, a decline from the 92–94% documented earlier in the shift. Lung sounds clear in the upper lobes bilaterally and in the left lower lobe; right lower lobe diminished with dullness to percussion. Vocal fremitus increased over the right lower lobe. Cough productive of moderate amounts of yellow-green sputum. Patient reports pleuritic right-sided chest pain rated 7/10 with inspiration, self-limiting his depth of breathing. Albuterol MDI, two puffs, given at 0030 with minimal bronchodilator response noted.

Heart rate 122 in regular sinus tachycardia, confirmed on telemetry. Blood pressure 162/102, MAP 122. S1 and S2 present and distinct; no murmurs, rubs, or gallops auscultated, no S3 or S4. Peripheral pulses 2+ bilaterally at radial and dorsalis pedis sites. Capillary refill under 2 seconds bilaterally. Skin warm and diaphoretic. No jugular venous distension. +1 bilateral lower extremity edema noted at the ankles — patient reports this has been his baseline since approximately 2023.

Abdomen soft, round, non-tender, and non-distended. Bowel sounds present and normoactive in all four quadrants. No guarding or rebound tenderness; no palpable masses or organomegaly. One episode of emesis at 0300, 75 mL yellow-brown liquid, Zofran administered with relief reported. Appetite markedly decreased — patient consumed approximately 30–40% of his dinner tray. Decreased PO intake for the past two days per history. Last bowel movement 02/13 at home, patient reports normal consistency and effort.

Foley catheter in place since 02/14 at 1430, 16 French with a 10 mL balloon, draining freely. Urine amber-yellow and slightly concentrated, no cloudiness or odor noted. Tubing positioned below bladder level with no kinks observed. Output 95 mL at 0500 and 80 mL at 0700.

Skin warm and diaphoretic throughout. Skin intact — no breaks, wounds, rashes, or bruising. Bony prominences at the coccyx, heels, and sacrum intact without erythema. Braden Scale score of 18. IV site at the left forearm, 20-gauge: no redness, swelling, warmth, or signs of phlebitis; site patent, flushes freely, infusing without resistance. Mucous membranes mildly dry.

Full active range of motion in all extremities. Grip strength 4/5 bilaterally, limited somewhat by fatigue and mild myalgias the patient describes as diffuse muscle aching. Pedal pushes equal and 4/5 bilaterally. Patient is an independent ambulator at baseline; in-hospital activity currently limited by dyspnea and pleuritic chest pain. Currently on bed rest with bathroom privileges and fall precautions in place. Grip socks on, call light within reach, bed in lowest position with alarm active.

Patient alert, cooperative, and appropriately anxious given his rising fever and worsening respiratory symptoms — repeatedly asking staff about his oxygen levels and when he might start to feel better. No prior psychiatric history. Interacts appropriately with staff; wife visited earlier in the shift and is expected to return in the morning. Denies feelings of hopelessness or thoughts of self-harm. Expresses frustration at being hospitalized mid-semester, since he works as a high school PE teacher, but verbalizes understanding of the need for treatment.

Peripheral IV 20-gauge in the left forearm, placed 02/14 at 1400. Site patent, flushes easily with positive blood return, no redness, swelling, or warmth. Dressing clean, dry, and intact, dated. Currently infusing Vancomycin per schedule without resistance. Foley catheter 16 French with a 10 mL balloon, inserted 02/14 at 1430, draining freely, tubing positioned below bladder level with no kinks. Foley care due every 8 hours per order.

Standard Precautions only. Contact precautions initiated at admission were discontinued 02/14 following a negative MRSA nasal swab and bedside and lab review — isolation had been placed in error on admission and was not clinically warranted. No current multidrug-resistant organism history and no active isolation order.

Fall risk assessed as moderate to high per facility scale, with contributing factors including fever, tachycardia, and illness-related deconditioning increasing orthostatic hypotension risk with position changes. Bed in lowest position, wheels locked, call light within reach, bed alarm active, grip socks on. Ambulation currently limited to bathroom privileges with assist.

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