Grace Santos is a 45-year-old female patient admitted to hos

Grace Santos is a 45-year-old female patient admitted to hospital 3… Grace Santos is a 45-year-old female patient admitted to hospital 3 days ago with adiagnosis of pneumonia. IV access was initiated 74 hours ago. The RN used a 20 gcathlon and was successful on her 2nd attempt at initiation. The IV is insitu in theright forearm.Grace has been on IV antibiotics now for 72 hours and has shown great improvement.Grace has been receiving cefuroxime 750 mg IV q8h x 5 days. Cefuroxime wasadded to 100 mL bag of NS>Grace is allergic to penicillin and has experienced an anaphylactic reaction in thepast.Grace has no significant medical hx and takes no prescribed medications.This morning her WBC count was within normal limits and her respiratory status hadimproved.However, over the last 4 hours you have noticed her respiratory status has declined,she is sitting up in orthopneic position, and you have auscultated coarse crackles tothe bases of both lungs. Her O2 sats are now 90% on RA. Her BP is 145/80, HR 100and RR 26. Her temp is 37oC.Her IV has been infusing at 150 mL/hr now for the past 3 days. Grace had her lastdose of IV antibiotics at 0600. The secondary line is still hanging with the last emptybag of antibiotics still hanging. The IV pump was cleared at 0600 before her dose ofantibiotics.The primary and secondary tubing are labeled. The tubing was originally primed 74hours ago. The bag of NS is labeled.It is 0700 and your 12-hour shift has just begun.Her urine output has decreased and the following physician orders have beenreceived:Furosemide 40 mg IV stat (added in a 50 mL bag of NS)Ventolin 2.5 mg by nebulizer q2h PRNSaline lock IV between antibiotic dosesStrict intake and outputDaily weightCBCelectrolytesO2 to keep sats above 92%What do you think is happening?What other assessments will you need to make?How will you collaborate with the RN?Documentation required:? 24 hour fluid balance record – complete for your shift? focus charting:o initial assessment completed at 0730o any follow up assessments related to medication administration? MAROther Data:Integrated Nursing Practice III Charting Assignment 14Intake:? 0800 – 1 cup coffee, 4 oz milk? 1000 – 12 oz water? 1200 – 1 cup tea, 120 mL jello.? 1400 – 12 oz water? 1700 – 1 cup milkOutput:? 0630 – urine – 50 mL? 0900 – urine – 600 mL? 1000 – urine – 500 mL? 1200 – urine – 550 mL? 1330 – urine – 450 mL? 1600 – urine – 350 mL? 1800 – urine – 300 mLHealth Science Science Nursing NUR 101

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