A nurse working in the emergency department (ED) is admitting a client. Exhibits Click to highlight the findings that require immediate follow-up. To deselect a finding, click on the finding again. Nurses' Notes Day 1, 1030: Client reports feeling short of breath, productive cough with yellow sputum, and pleuritic chest pain. Runny nose, myalgia along with headache for the past 3 days. "I woke up feeling worse and started to feel nauseated and couldn't eat my breakfast, so I thought I should come in." Client reports pleuritic chest pain as 6 on a scale of 0 to 10. Skin is moist. Lungs sounds are diminished in lower lobes with crackles. Bowel sounds are normoactive in all quadrants. Last bowel movement this morning. Reports no difficulty urinating. Reports nausea with no vomiting. Able to move all extremities. Pedal pulses present +2. Client is oriented to person, place, and time.

Feeling short of breath: Rationale: Shortness of breath is a critical symptom, especially in a client with a recent diagnosis of pneumonia (right lower lobe pneumonia seen on chest x-ray). It indicates impaired gas exchange and requires immediate evaluation to ensure the client’s oxygenation needs are being met and that the condition isn’t worsening. Given the oxygen saturation was 88%, this symptom is concerning and requires prompt intervention, such as increasing oxygen therapy. Pleuritic chest pain: Rationale: Pleuritic chest pain, often described as sharp or stabbing pain that worsens with breathing or coughing, is commonly associated with conditions like pneumonia or pulmonary embolism. In this case, the client has pneumonia, which can cause inflammation of the pleura (the lining of the lungs) and lead to pain. This symptom requires monitoring and potentially further evaluation to assess the extent of the pneumonia and its complications. Headache for the past 3 days: Rationale: A headache lasting several days could be related to the underlying infection or a systemic response to it (fever, dehydration, etc.). Although a headache is not an immediate emergency, it may indicate that the infection is severe or complicated, especially in the context of fever and other systemic symptoms like nausea. It is important to monitor the client's neurological status as part of their overall condition. Nausea: Rationale: Nausea, especially in the setting of a respiratory infection like pneumonia, can indicate that the infection is affecting the gastrointestinal system or could be a side effect of medications (e.g., antibiotics). It is important to evaluate the cause of the nausea and address any concerns related to fluid and electrolyte balance, particularly because the client has not been eating well, which could lead to dehydration or malnutrition. Lung sounds diminished in lower lobes with crackles: Rationale: Diminished lung sounds with crackles suggest fluid or consolidation in the lungs, which is characteristic of pneumonia. This finding requires immediate attention because it could indicate worsening pneumonia or atelectasis. Monitoring and interventions, such as increased oxygen support, encouraging deep breathing, and using the incentive spirometer, are essential to prevent further respiratory decline.