Patient Name: John Smith
Triage RN: L. Hernandez, RN
Triage Acuity Level: ESI Level 2
Chief Complaint:
"Shortness of breath, fever, and confusion for the past day."
Subjective:
68-year-old male presents to ED via private vehicle with family. Reports worsening shortness of breath, chills, and confusion over the last 24 hours. Family states he has been increasingly lethargic and disoriented today. No history of trauma. Denies chest pain but says he feels “very tired” and “not right.”
Objective:
Appearance: Pale, diaphoretic, confused but responsive to questions
Vital Signs:
BP: 90/55 mmHg
HR: 110 bpm
RR: 28/min, labored
Temp: 102.5°F
SpO₂: 88% on room air
Breath Sounds: Bilateral crackles at bases
Skin: Warm, flushed, moist
Neuro: Alert but intermittently confused, follows commands slowly
Allergies: NKDA
Medical History: Hypertension, Type 2 Diabetes, Chronic Kidney Disease (Stage 3)
Medications: Lisinopril, Metformin, Atorvastatin
Initial Nursing Interventions:
Placed on 2 L/min oxygen via nasal cannula
Pulse oximetry and cardiac monitor initiated
Patient escorted to treatment room in wheelchair with continuous monitoring
Provider notified of arrival and symptoms
Clinical Impression:
Signs and symptoms consistent with sepsis and possible community-acquired pneumonia. Requires urgent evaluation and intervention.