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Case study 1 Part one

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Case study 1 Part one

Case study 1 Part one (morning shift)

Bedside handover is as follows: (read by Lab session tutor)

Patient transferred from the Emergency Department to the Respiratory Medical Unit

Date: 30th July 2018   Time: 10.00 hrs

Identification: Jim Cooper, 68 year old male

Situation:

Jim presented early this morning with a 1 week history of productive cough and SOB more than usual. Has been to GP for Oral AB. Reports having to sit in a chair all night the past few nights and is finding it more difficult to care for himself at home. He lives alone. Patient mentioned that the drinking helps him to calm down. Patient expressed that he had been feeling lonely and it has been getting him down the past few months.

Past medical history:

COPD diagnosed 5 years ago

Reflux

Hypercholesterolaemia

Assessment:

Vital signs on admission to the emergency department:

HR        118 beats/min

RR          36 breaths/min

SpO2      88% RA – 93% 2L O2 NP

BP          146/92 mmHg

Temp    38˚C oral

 

Auscultation: Scattered wheezes throughout both lung fields

Recommendation:

Treatment with oxygen, IV fluids, IVAB, Prednisolone and physiotherapy.

Integrated Nursing Practice: Spring session

University of Technology Sydney

Subject Coordinator Carmen Axisa



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