21 August 2024
I – Introduction
- Name: Desiree Contes
- Title: Student Nurse
- Reason for Being There: Clinical Rotation
S – Situation
- Patient: Will Emerson
- Age: 56 years old
- Gender: Male
- Height/Weight: 175 cm / 70 kg
- Allergies: Penicillin, Morphine, Sulfate
- Code Status: Full Code
- Privacy Code: Not specified
- Date/Time of Care: 1/15/2022, 10:00 AM
- Attending Physician: Dr. James
- Chief Complaint: Increasing difficulty breathing
- Pathophysiology of Primary Medical Diagnosis: Evolution of adverse functional changes associated with a disease (specific disease not mentioned)
B – Background
- Past Medical History:
- Chronic Obstructive Pulmonary Disease (COPD)
- Current Medications:
- Oxygen (2 LPM)
- Xopenex
- Social History:
- Social drinker
- Previous 2 pack-a-day smoker
A – Assessment
- Vital Signs:
- Blood Pressure (B/P): 156/60 mmHg
- Heart Rate (HR): 110 bpm
- Respiratory Rate (RR): 34 breaths/min
- Temperature (TEMP): 103°F / 39.4°C
- SpO2: 92% on 2 LPM oxygen
- Pain Level: 4/10
- Falls Risk: High
- Accu Check: Not provided
- IV Site: Not specified
- IV Fluids: Saline
- Isolation Precautions:
- Yes (COVID-19 positive)
- Wear mask and quarantine at all times
- Respiratory:
- Rhonchi in all fields
- Intercostal retractions bilaterally
- Cardiovascular:
- Sinus Tachycardia
- Audible S1 and S2, no murmurs
- Neurological:
- Alert and oriented to person, place, and time
- HEENT:
- Skull is normal cephalic
- PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation)
- Gastrointestinal/Genitourinary (GI/GU):
- Hyperactive bowel sounds
- Abdomen soft, round, no pain on palpation
- Voiding dark yellow urine
- Dietary History:
- NPO (Nothing by mouth)
- Integumentary:
- Skin pale, hot, diaphoretic
- Musculoskeletal:
- General weakness
- 1+ pitting edema in lower extremities
- Radial and pedal pulses weak bilaterally
- Psychological/Family Support:
- Supported by wife
- Safety Teaching Needed:
- Isolation precautions
- Mask-wearing
- Bed rest
- Labs/Tests Abnormal:
- CBC
- BMP
- Chest X-ray (ordered)
- Flu test (ordered)
- COVID test (ordered) – STAT
R – Request/Recommendation
- Recommendation:
- Place on isolation
- Stat chest X-ray
- Labs: CBC, BMP, Flu test, COVID test – STAT
- Hold all current home medications
- Notify physician once all results are available
- Hand Off Report:
- From: Desiree Contes, Student Nurse
- To: Professor Ufundo