CARE PLAN TEMPLATE BUNDY.docx
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School
West Coast University *
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Course
840
Subject
Medicine
Date
Dec 6, 2023
Type
Pages
7
Uploaded by ColonelMorningKangaroo7
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SBAR NURSING NOTE SITUATION Good afternoon professor Ofoleta, the following is an report regarding my patient Bundy in room 1234. He is a 75 y/o farmer who has a long history of COPD from his heavy smoking habit. He was admitted into the ED with a medical diagnosis of Acute COPD exacerbation as evidenced by his SOB at rest, febrile state at , and productive thick green sputum cough with inspiratory and expiratory wheezes. Physical assessment findings include cyanotic signs to the lips, a barrel chest and warm diaphoretic skin. Bundy also has some noncompliance due to medication expenses he can’t afford. BACKGROUND Bundy states he ran out of inhaler medication a week ago. Wife reports he has been unable to speak in full sentences for the whole day, she also reports that there has been no changes in his mental status. Sputum culture still needs to be collected, however CBC results display leukocytosis and low hemoglobin. Bundy has been breathing in a tripod position, using his accessory muscles to breathe. He has no known allergies, advance directives set to DNI, fall risk is low, and is to stay on bed rest with bathroom privileges. ASSESSMENT -
VS: -
A/O x 4 -
Oxygen saturation = 86% on 3L of O2 nasal cannula -
Coarse crackles at bases of lungs -
Given 650 mg acetaminophen to relieve pain, 1 mg lorazepam to relieve anxiety, and 60 mg methylprednisolone do decrease inflammation -
Blood cultures x 2 -
Titrate supplemental O2 until SpO2 reaches 88-92% goal
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Monitor fever -
Continuous pulse oximetry -
Collaborate with respiratory therapist and suggest chest physiotherapy -
Form teaching plan for smoking cessation -
Ensure ECG in 24 hrs RECOMMENDATIONS Once Bundy’s sputum culture test results return, his VS should be under strict monitoring since he is starting to display signs of infection through discovered leukocytosis and a fever, I would recommend maintaining adequate fluids and aim to reduce fever within 24 hours by recommending to HCP for an antibiotic prescription. Respiratory therapist consultation should be considered to formulate a daily breathing treatment plan. Social workers should also be requested to prepare options for medicine funding and government assistance for nutritional needs once discharged.