Question

Vincent Brody is a 67 year old male admitted directly from physician office for exacerbation of Chronic Obstructive Pulmonary Disease (COPD). He has been assisted into a patient gown and in the hospital bed. He is hunched forward in apparent respiratory distress. His wife is very attentive at his side. Physician orders have been obtained. Mr. Brody remains afebrile throughout the case. He is been smoking over 50 years. This is the 3^rd exacerbation of the COPD. He is constantly complaining of fatigue, he cannot move around easily without help and he can’t sleep well at night and heard cough.

Vital signs of the patient on 2L nasal prongs are: heart rate: 90 beats/min, SpO2: 92, Respiration: 28 BP: 143/85

1) Vital signs are complete. Are you concerned about the results? Are there any interventions you think you should initiate?

2) During your assessment you note that Mr. Brady has a barrell chest and slight clubbing of the fingers. He is exhibiting increased work of breathing, but otherwise your assessment is unremarkable. You leave the room and proceed to give report to the physician. Construct your report using the SBAR format highlighting key findings and concerns.

Answer 1

1)The respiratory rate and BP are high. Normal RR is 12-16/min and BP is in between 90/60-120/80 mm Hg. Interventions for high RR can be breathing training, cool wall breathing, chest wall vibrations. For high BP, control in diet such as low salt, no smoking should be advised first. If not controlled, then medications can be given.

2) Situation:- Mention current case scenario such as breathing issues, high BP, clubbing of nails(due to low oxygen available to the body).

Background:--Includes all the previous medical history, habits such as smoking, twice admission due to COPD.

Assessment:-the person is suffering from COPD, dyspnea, high BP, high respiratory rate, low oxygen availability, air

Recommendations:-nebulisation, breathing exercises, low salt diet, medications to prevent infection such as antibiotics.