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