INTRODUCTION Amy, RN, medical surgical unit
Your name, positon (RN), unit you are
working on
SITUATION Vincent Brody, 67-year old male, exacerbation of COPD
Patent’s name, age, specific reason for visit
BACKGROUND P
...
INTRODUCTION Amy, RN, medical surgical unit
Your name, positon (RN), unit you are
working on
SITUATION Vincent Brody, 67-year old male, exacerbation of COPD
Patent’s name, age, specific reason for visit
BACKGROUND Patient is diagnosed with COPD, he was admitted on June 27, 2020.
Patient currently is experiencing a productive cough. Patient has a 50-
year history of smoking 2 packs a day. During the last year he had two
exacerbations. Patient’s current orders include: continuous ECG, SpO2
monitoring, and vital signs every 5 minutes, O2 via nasal cannula to
keep O2 greater than 90%, IV: potassium chloride in 5% dextrose and
normal saline at 100 mL/hr, arterial blood gas, and Albuterol 2.5 mg in
3 mL normal saline via nebulizer every 20 minutes x 3 doses.
After developing left-side pneumothorax patient’s orders were as
follows: chest tube insertion, obtain chest x-ray before and after chest
tube insertion, morphine 2mg via IV push prior to chest tube insertion,
100% oxygen.
Patent’s primary diagnosis, date of
admission, current orders for patent
ASSESSMENT Patient is experiencing a productive cough. Physical findings include
barrel chest and clubbed fingers. Patient vital signs were as follows:
respiratory rate- 21 breaths per minute,
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