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NS118 RLE
( 7 : 0 0 a m – 11 : 0 0 a m )
Morning shift

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 Patient’s (Form/s) Allocation
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Jake Yvan Dizon
Bon Mark Bautista
Rhealyn Velasquez
Myles Jewel Soriano
Lucy Marie Ison
Team Leader, ISBAR,
Registration Sheet, Daily
Checklist, and Health
Assessment
Fall assessment, Nurses notes,
IVF Sheet, and VS Sheet
I and O, NCP, and Health
Teaching
MAR, Laboratory Result, and
Imaging Result
MD Progress Notes, Consent, Pre-
OP Checklist, and OR Consent
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IDENTITY OF PATIENT
N A M E : J O A N WA L K E R
AGE: 84 YEARS OLD
MRN: AB1248
WA R D : G E R I AT R I C WA R D
T E A M : 7 - 11 S H I F T

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SITUATION
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• SYMPTOM / PROBLEM:
- Difficulty of breathing
- Productive cough with Green
phlegm started 4 days ago that persists.
- Intermittent Chills
VITAL SIGNS:
- Temperature: 39.6C (oral)
- Pulse: 110
- Respiratory: 30
- Blood Pressure: 178/96
- O2 Saturation: 86% room air

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PATIENT STABILITY / LEVEL OF CONCERN

• Patient appears anxious and in
distress
• Alert & Oriented to person, place,
time, and situation.
• The patient has difficulty of breathing
during the night and has been using
albuterol inhaler q1-2h with no
improvement.

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BACKGROUND
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• HX OF PRESENTATION:
Mrs. Walker started three days ago
on prednisone 40mg PO, daily and
zithromycin 250mg PO x5 days as
prescribed by her physician. She had
intermittent chills, and fever last night of
38.9C. She has had more difficulty
breathing during the night and has been
using albuterol inhaler q1-2h with no
improvement. She also have persistent
productive cough. The patient reported
having history of COPD.

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BACKGROUND
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• Date of admission and diagnosis:

• September 14, 2021
• Community Acquired Pneumonia
• Relevant past medical history:
• The patient have a history of COPD.

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ASSESSMENT title style
AND ACTION
• - What is your diagnosis/ impression of situation?
• Pt. has pneumonia regarding the following diagnostic test results
• x-ray shows that left lower lobe infiltrated and the present of hypoventilation.
• ABG which is ph=7.25 which low, pCO2=68 which high, HCO3=36 high so
(showing respiratory acidosis) also indicated Chronic CO2 retention
• CBC (WBC (14.5) RBC (13.3) PLTs(217) Neuts(%92)- which indicated full
inflammatory response to infection w/ aggressive neutrophil count presentage so pt.
should give antibiotic

• WHAT HAVE YOU DONE SO FAR?

• Monitored Vital signs
• Administered 6lpm oxygen
• Administered the following medications
1. Atrovent (Ipratropium Butylbrumide) 2.5mg + 2ml NS NEB q 4 hourly, and NS
2ml NEB after 2 hours
2. Methylprednisolone 125mg IV push STAT
3. Levofloxacin 750mg IVPB q 12hours after Blood culture x2 to which is
Bronchodilator which dilate the vessels to improve oxygenation

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RESPONSE ANDMaster title style
RATIONALE
Intervention Rationale
Provide assurance and reduce anxiety. Anxiety increases dyspnea, respiratory rate, and work of
  breathing.
   
   
Position patient in semi fowler position  
  This will help in lung expansion and breathing
   
   
Monitor patients vital signs.  
  Provide crucial information of patient’s condition
   
   
Instruct patient to do deep breathing and help increase sputum clearance and decrease cough
controlled coughing spasms.
   
Instruct patient to limit exposure to persons with  
respiratory infections Reduce spread of potential droplets between patients
   
   
   
   
   
Administer medications and oxygen flow as  
prescribed To decrease signs and symptoms of patient condition
 
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RESPONSE ANDMaster title style
RATIONALE
Intervention Rationale
Monitor Vitals signs To provide crucial info. On patients condition
   
  To receive right amount of fluid and help to reduce fever.
Increase intake of fluid  
   
  This will help to decrease abnormal body temperature
   
Perform Tipid sponge bath  
  This will help for easily escape of increase body temp.
   
   
Remove excess clothes such as jackets,  
pants  
  This will help to reduce body temp internally
 
 
 
Medications as prescribed .

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REVIEW:

• Blood Culture for 24 hours

• Continue Monitoring of:
• Blood Chemistry (Glucose)
• ABG
• Serum Electrolytes

• 09-14-21 (7-11AM)

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THANK YOU!
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