Sally Carson is a 66-year-old female who has transferred from the ICU. She was initially admitted to the ICU from the ED two days ago, complaining of sudden onset of a severe headache and dizziness but no loss of consciousness. She underwent an emergent head CT that demonstrated bleeding in the left frontal temporal area. She has a past history of atrial fibrillation treated with rivaroxaban.
She is alert and oriented to person, place, and time. PERRLA. VS: Temp: 97.9 F/36.6°C, HR: 76, RR: 14; BP: 158/90. Moving all extremities; right side weaker than left. Slight drooping of the right side of the mouth. Headache is less intense than on admission and responds with acetaminophen. She is receiving oxygen at 2L per nasal cannula. Respiratory rate 14 to 16 with coarse crackles noted in the bases. Atrial fibrillation on cardiac monitor; peripheral pulses weak but palpable. Skin intact with no signs of pressure injury. She is voiding clear urine using bedside commode. Patient allowed up with assistance.
18 gauge IV in left forearm infusing 0.9% sodium chloride at 70mL/hr. The second 18 gauge catheter is saline locked.
