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Pt Mrs, D in room 118 had labs drawn this morning at 0630. Results came back confirming she had gram postive rods present in her blood. Pt is currently on antibiotics to treat pneumonia. I feel that more specific antibitocs may be needed due to this new information, I am requesting a more specific antibiotic to treat the  gram positive infection.
Thank You, Emily x8118

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Pt K in room 106 with elevated HR.  Patient vomiting for last 24 hours with recent decrease in nausea but Pt still refusing PO intake.  Vital signs show HR of 110 and BP 110/50.  I think  patient is becoming  dehydrated and request IV fluids be ordered and holding the two BP meds that are due.  Thank you, Kate. x2302

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Pt. S in room 10 with IV infiltration. IV vancomycin was infiltrated at 1210, 10 minutes after starting dose. Pain, redness and swelling was noted. IV was stopped and disconnected and the IV team was called for a new site.
Will monitor for any skin changes at infiltration site. No further distress noted. Thank you. Sonya x1234

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Pt. C in room 104 fell out of bed, unwitnessed, during night shift. Pt. vital signs and Glascow Coma scale WNL. Pt. denies hitting head and no injury is noted. I will continue to monitor patient vitals and pain scale and implement safety considerations- bed alarm and side rails up.
Thank you
Chloe
x2222

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Pt S in room 100 with fever.  Patient had a fever of 38.5 and experienced chills and a headache, with all other vital signs stable.  Tylenol PRN was given and fever was reduced.  No further distress noted.  Thank you.
Summer

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Pt. M in room 400 with potassium imbalance. Patient has received a dose of 40mg IV lasix yesterday and I witheld the dose that is due today because her potassium level have drop down to 3.1. I think that this patient needs a potassium supplement order.
Please and thank you, Ming C.

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Pt Mr. J in room 230 with increased oxygen requirements. Pulse ox decreased to 87 percent on 3 lIters with slight increased work of breathing. Increased to 5 liters, pulse ox now 94 percent. No further distress noted. Thank you. Jennifer X5400.

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You review your patient's morning labs and note your patient's potassium level is at 3.1. You notice your patient received a one time dose of lasix 40mg IV yesterday and she is due for lasix 40mg IV today. The EMAR does not reflect an order for a daily potassium supplement.

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You initiate your patient's 1200 vancomycin dose. After 10 minutes your patient rings the call bell and complains of pain at the site. Upon assessment of the site, you note redness and swelling. You disconnect the vancomycin and page the IV nurse for a new site.

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You flush your patient's port and are unable to obtain blood return. You troubleshoot by repositioning the patient and still unsuccessful. The IV nurse attempts and is also unsuccessful. You have IV medications due to administer.

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Pt has been afebrile since admission. Pt complains of chills and headache. Vitals shows temp at 38.5 and otherwise stable. You note an order for Tylenol PRN temp >38.5.

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You receive a call from the lab. The lab tech reports positive blood cultures with gram positive rods. Pt is originally admitted for pneumonia and is being treated with antibiotics.

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Pt has been nauseous and vomitting since yesterday. Currently patient states "nausea is okay". Vital signs noted at 110/50, HR110. Pt is on two blood pressure meds that are due and there are no hold parameters. Pt has no IV fluids ordered. Pt is refusing PO intake due to her nausea.

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Pt has a history of COPD and is admitted with hypoxia.  During shift, you note patient pulse ox reading is at 87 percent and patient shows a slight increase in work of breathing. You  increase his oxygen from 3L-5L. Pulse ox now at 94. Patient breathing appears stable.

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You are working night shift and hear a bang. You enter your patient's room and she is sitting n the floor. Vital signs and Glasgow coma scale are within normal limits. No apparent injury noted and patient denies hitting her head. You assist her back to bed.