Allyson RN, Cindy ED RN, Jessica RN, Cody RN, Dr.

Simpson PCP, Hector Gomez Pt, Rosa

Gomez (Pt daughter), Maggie (Assistive Personnel), Dan RT, Jillian RN, Janelle RN, Elsie RN
CHARGE, Dr. Peetze PCP, Donna Clinical Nurse Specialist

Allyson on a general medical unit is given a report from Cindy from the ED: Mr. Gomez 68 yrs
old has pneumonia, exacerbation COPD, the daughter found him on floor at home,
unresponsive. He recently lost wife and abuses alcohol. T 99.2, P 100, RR 36, O2 @ 91% 5L
NC. Diminished lung sounds in bases, occasional rhonchi, wheezes in both A&P upper lobes,
productive cough, greenish-yellow tenacious sputum. BP 150/94, no pain. Looks anorexic, alert
and oriented. Saline lock L wrist IV, flushes fine, 250 clear yellow urine, NPO, no antibiotics
given yet, but 2 albuterol neb tx. Labs pending: ABG, blood alcohol, CBC, CXR, chem and
metabolic profile, UA, culture & sensitivity of sputum.

I chose Code status, ABGs, Last dose of bronchodilator medication.

Nurse Allyson introduces herself and nurse assess resp status of crackles, takes O2 sat, RR15,
neuro status. Pt knows its a hospital but not which one and is very tired.

I chose to decrease the rate of O2 flow

Check pt and id and birthday. Dr ordered Ceftriazone, Soft diet, though not hungry right now

I chose to put videos in order BDACE

I chose to put 200 mL/hr

Daughter mentions that dad’s skin is itchy and dry and requests lotion.

I chose “I’ll be right there”

What I reinforced: -Cillins and Cefs- have related allergies sometimes

Nurse sets urine collector on counter washes hands and visits pt

No breathing diff, turns off IV meds, checks pt BD and name, checks RR and Vitals. Nurse
informs the allergy rxn and will update the records and inform Dr to order new antibiotic and
then flushes the IV with saline. Also do not scratch it will be hard.

I chose to Assess Mr. Gomez’s breathing pattern.

Daughter is very worried and Dad thinks she’s overreacting. Daughter is afraid that her father
smokes and drinks too much and that he won’t be able to reach the phone when he is unable to
breathe effectively.
 I chose to Encourage Mr. Gomez and his daughter to further express their emotions

RT reports to the charge after albuterol tx, there are diminished lungs further, pt complain
pleuritic chest pain, increase SOB, there was a lack of CXR. After, doctor diagnosed pleural
effusion and orders a thoracentesis. Nurse said: in chair and cough and deep breathes and
incentive spirometer didn’t work well. Dr says maybe needs chest tube, has a new order just in
case.

I chose A

This night he has pain in his side and has a hard time taking a deep breath. Pt requests to
increase O2 and Maggie goes and grabs his nurse

I chose Assess all tube connections between the chest and the drainage system

Side still hurts, hard to breath, checks the chest tube, informs him to continue incentive
spirometer, and goes to get acetaminophen and orders RT tx

I&O recorded after breakfast tray, Allyson nurse will educate pt about his dietary habits and
discuss his labs, Maggie will give hi bath so requests to educate later with daughter present

I chose Prealbumin
It was good to remember and reinforce that prealbumin is an EVEN more sensitive
indicator of protein deficiency!

Mr. Gomez injured his arm!! (maybe the CNA hurt him but she worded it this way! Quite
interesting)

I chose Alcohol intake, History of corticosteroid use, Limited mobility, Chronic illness
(COPD)

Nurse Allyson does discharge teaching on diet and meter-dose inhaler. Video educates:
Disperse medication to lung via mist/aeorosol spray/fine powder. 1-2 inches away from open
mouth. Deep breath then exhale completely. Inhale 3-5s as you depress completely. Hold
breath 10s. To make sure it reaches the lower airways as well

I chose Begin a pulmonary rehabilitation program