The nurse reviews the entries in the medical record. Exhibits Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again. Laboratory Results 1800: WBC count 6,700/mm3 (5,000 to 10,000/mm3) Hemoglobin 12 g/dL (14 to 18 g/dL) Hematocrit 36% (40% to 52%) Vital Signs 1800: Blood pressure 112/74 mm Hg Heart rate 95/min Respiratory rate 18/min Temperature 37.5° C (99.5° F) Oxygen saturation 100% via 2 L/min nasal cannula Assessment 1800: Physical Exam: General: no distress HEENT: oropharynx clear, mucous membranes moist and pink Respiratory: bilateral breath sounds clear Gl: epigastric tenderness to palpation, no rebound tenderness or guarding Neuro: awake and alert
Explanation & Rationale
Blood Pressure: 112/74 mmHg (Previously 76/45 mmHg): The client's blood pressure has stabilized, suggesting improved circulatory volume and perfusion. Heart Rate: 95/min (Previously 121/min): A decrease in heart rate indicates improved hemodynamic stability and a reduced compensatory response to blood loss. Hemoglobin: 12 g/dL (Previously likely lower due to GI bleeding): Hemoglobin has improved, indicating successful correction of anemia, possibly due to blood transfusion. Mucous Membranes: Moist and Pink (Previously Pale): Improved mucosal color and hydration suggest better oxygenation and volume status. General Assessment: No Distress (Previously Diaphoretic, Uncomfortable): The client no longer shows signs of discomfort or distress, indicating symptom relief and better overall condition. Oxygen Saturation: 100% on 2 L/min Nasal Cannula (Previously 98% on Room air): The client is maintaining adequate oxygenation with minimal supplemental oxygen. Epigastric Tenderness Without Guarding or Rebound Tenderness: No worsening of GI symptoms suggests that the treatment plan (transfusion, IV fluids, and PPI therapy) is effective.