University:
West Coast University
Course:
NURS 122 | Introduction to Medical Surgical Nursing
Academic year:

2022
Views:

222

Pages:

1
Author:

Killian Mata

INTRODUCTION 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 Patent’s primary diagnosis, date of admission, current orders for patent ASSESSMENT Current pertnent assessment data using head to toe approach, pertnent diagnostcs, vital signs RECOMMENDATION Any orders or recommendatons you may have for this patent Patient is diagnosed with COPD, he was admitted on June 27, 2020. Patient currently is experiencing a productive cough. Patient has a 50year 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. 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, O2 sat- 93%, Pulse- strong 105 beats per minute and regular, blood pressure- 130/78 mmHg, Temperature: 99 F (37 C), Normal skin turgor, normal skin color, and not sweating, ECG- sinus tachycardia. When auscultating the lungs, there were a few audile wheezes heard in the chest, heart sounds were normal. Arterial blood gases suggested respiratory acidosis. After developing left-side pneumothorax, patient experiences chest pain, and has reduced breath sounds on the left side. Prior to hand off and after chest tube insertion patient’s vital signs are as follows: ECG: Sinus tachycardia. Heart rate: 118. Pulse: Present. Blood pressure: 128/77 mm Hg. Respiration: 34. Conscious state: Appropriate. SpO2: 93%. Temp: 99 F (37 C). I recommend continuing to monitor the patient’s vital signs every 5 minutes. I also recommend assess the patient’s chest tube insertion site and dressing. Continue to monitor the patient frequently. Provide patient education, specifically on smoking cessation.