Time: 0730, day 1 after admissionChange of shift report:Henry Williamsis a 69-year-old retired rail

Time: 0730, day 1 after admissionChange of shift report:Henry Williamsis a 69-year-old retired rail system engineer who lives in a small apartment with his wife. He was admitted during the night with progressive shortness of breath. His oxygen saturation on admission was 82% on room air. He has a history of COPD and coronary artery disease, and is hard of hearing. His oxygen saturation has improved and is now running 88% on oxygen 2 L/min by nasal cannula. His respiratory rate has been 24-30/min.Henry is concerned about his wife, Ertha, because she is experiencing frequent memory lapses. Ertha went home with their daughter-in-law, Betty, and they have just returned. Due to his shortness of breath the admission is not complete. A fall risk assessment has been done and indicates a moderate fall risk, but he still needs an overall assessment. Blood pressure has been 134/88 mmHg, pulse was 112/min, and respirations were 28/min. He is alert and oriented. The morning labs were just drawn, and the physician wants to know the arterial blood gases. Henry denies pain and says he is just tired.Patient DetailsPatient Data: Male- Age: 69 years. Weight: 88 kg (194 lbs). Height: 183 cm (72 in).Allergies: PenicillinPast Medical History: Chronic obstructive pulmonary disease (COPD), cardiovascular disease (CVD), asthma, hearing loss (wears hearing aids).History of Present Illness: Patient was admitted last night with an acute exacerbation of COPD. He was not able to catch his breath and his doctor told him to go to the emergency room. His neighbor brought him to the emergency room. He is concerned about his wife, Ertha, who has problems with memory and seems confused at times. His daughter-in-law Betty is a nurse. She mentioned that Henry appears depressed, and noted that his appetite has diminished over the past two months and he has lost some weight. He has also lost interest in his previous activities, such as following major league football and working on crossword puzzles. Betty will look after Ertha while Henry is here.Social History: Retired.Primary Medical Diagnosis: COPD, cardiovascular disease.Surgeries/Procedures & Dates: Appendectomy at age 15.Provider’s Orders• Bed rest, bathroom privileges with assistance• Regular, low fat diet• I & ORespiratory treatment:• Albuterol nebulizer treatment 2.5 mg and ipratropium bromide 0.5 mg in 3 mL normal saline every 20 minutes x 3, followed by albuterol 2.5 mg and ipratropium bromide 0.5 mg in 3 mL normal saline every 2 hours (decrease frequency, as tolerated)• Titrate oxygen to maintain SpO2 at or above 90%• Lactated Ringer’s solution IV at 50 mL/h• Complete Blood Count (CBC)• Brain Natriuretic Peptide (BNP)• Basic Metabolic Profile (BMP)• Arterial Blood Gases (ABG’s)• Chest X-RayContinue home medications and add:• Prednisone 40 mg PO daily x 10 days• Lisinopril 12.5 mg PO daily• Metoprolol tartrate 50 mg PO daily• Acetylsalicylic acid 81 mg PO daily• Rosuvastatin calcium 20 mg PO every evening• Montelukast 10 mg PO every eveningHome medications:• Fluticasone propionate 250 mcg every 12 hours nebulized• Albuterol 2 puffs as needed for acute onset of shortness of breath1.Nursing care plan2.SBAR3.SOAP Notes Health Science Science Nursing NRSE 2030 Share QuestionEmailCopy link Comments (0)

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