1. The client appears short of breath, with wheezing in all lung fields.
2. The client is admitted with pneumonia and the nurse will watch for respiratory symptoms.
3. Respiratory treatments are given as ordered every 4 hours.
4. The client reports improved breathing after breathing treatments given.
1. The client appears short of breath, with wheezing in all lung fields.
Rationale: Documentation of a nursing assessment includes signs and symptoms and an indication of any actual or perceived problems.
In the given scenario, icd-10-cm code reported is H02.423.
What is icd-10-cm code?
The ICD-10-CM is a morbidity classification developed by the United States that is used to classify diagnoses and reasons for visits in all health care settings.
Upper eyelid drooping is caused by a muscle disorder (myogenic). Look for Ptosis/eyelid in the ICD-10-CM Alphabetical Index, which states to see Blepharoptosis.
Look for Blepharoptosis and you'll be directed to H02.423, where the sixth character indicates laterality.
The sixth character of three stands for bilateral. There is only one code for both eyelids, not two separate codes.
This, this should be the icd-10-cm code.
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