14TH CASE SCENARIO.(Nursing)DIFFICULTY BREATHING.

Emergency Room Report.

Patient: Lodogod,Way James.

Age 83years.

Sex : Male.

Date: 12/29/2010

MR: Q0000999629.

TRIAGE:

Triage time: 1850pm.

Acuity: Level 2

Chief Complaint :Difficult Breathing.

Diagnosis: Acute asthma exacerbation with pneumonia.

1850PM: BP 120/80,Hr: 76,Respiration 24,Temperature 98.2,02 Saturation 94%room air. Pulse oximeter applied.Alert and oriented ×4.

EMERGENCY MEDICAL SERVICE (EMS) treatment PTA (Prior to Admission)verbally communicated, Pulse oximeter applied,Cardiac monitor applied. Medication of Albuterol given 3times .Bp 150/79,Hr 102,RR 20 ,02 Saturation 93RA.

Weight 163Ibs,Height 5ft 4inches.

RN:Nicole Lovegod RN.

Medications Clarithromycin oral given at 1930pm by Nicole Lovegod,RN.

Albuterol- Ipratropium Inhalation at 1930pm by Nicole Lovegod,RN.

Allergy: NKDA

PMH: Coughing and wheezing ×3 days(Productive Coughing)Asthma, pacemaker,atrial fibrillation

ID band :placed on patient.

Abdomen soft and nontender,skin warm and dry.Cardiac rhythm:atrial fibrillation. No acute distress, no respiratory distress, respiration unlabored,expiratory wheezes in the left mid- lung posteriorly.

Two patient identifier checked.

MEDICATIONS:

Solumedrol 125mg diluted with IV fluid slow IVP via IV #1site left arm patent.IV site checked no pain,no redness ,#1 right antecubital space 20g angiocath,with aseptic technique, one attempt. Saline Lock flushed with 10ml saline. IV FLUIDS STARTED in Emergency department bag#1 – 1000ml NS.Rate wide open. Blood samples drawn:blood culture.

Rocephin 1gm mix in 10ml NS IVPB,IV PATENCY ESTABLISHED.

Tamiflu 75mg po.Confirmed right patient,medication, dose,time,and route. – Joselyn Whereisgod,RN.

0120AM :IV FLUIDS RATE CHANGED (Decreased to 100ml/hr.

Zithromax 500mg IVPB in 250ml(pre- mixed)over 1hour via pump.

ALLERGY: NKDA

0130AM:BP 129/80,Hr. 88,Respiration 20,02 Saturation 97% room air. Nohate,Michelle,RN.

Patient denies pain,calm and resting quietly.

Vital sign repeated Q30minutes . Patient remain stable.

Patient to be transferred to 4NorthEast.

Care transferred and report given to Winner,Emime,RN at 4NORTHEAST.

DISPOSITION/DISCHARGE:

Patient Belongings done in Emergency department.MRSA Swab completed.Bed request completed.Transfer pending to floor.

IV FLUIDS STOPPED bag #1.Total amount infused = 500ml.IV converted to saline lock.Fall risk completed, no fall risk,denied pain 0/10.Patient report fax to floor. Patient is transported via Stretcher by Nursing staff with IV.

Admission condition: Stable.

LABORATORY:

NA 138

Potassium serum 4.0

Chloride serum 108

Carbon dioxide 26

BUN 20

Creatine serum 1.03

WBC 7.0

Hemoglobin 14.0

Hematocrit 39.4

Platelets 100.

Neutrophil 57

Chest X- ray : Infiltrate in the right middle lobe.No fractures, Normal heart size.Mediastinum is normal.

Report: Great reporting by the medical team from EMS to the doctors and nurses.

PATIENT EDUCATION:

Patient and family very pleased with the care so far.And will be transferred to 4NORTHEAST.

They demonstrated understanding.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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