Question

Cindy calling in the Emergency Department. I’m sending Mr. Gomez. Who is experiencing pneumonia exacerbation of his COPD patient is 68 year old latino   Daughter   found him on the floor   where he lives by himself, she said his was unresponsive he recently lost his wife and there is a question of alcohol. His Temp is 99.2, pulse 100, respirations 36 and his sat is 91%on 5 liters of 2 per nasal canula. Lungs sounds diminished in a base. He has occasional bronchi   with wheezes in both the anterior and posterior upper lobes. His cough is productive of a greenish- yellow tenacious sputum. His   blood pressure is 150 over 94 he denies pain. He appears anorexic although I don’t know if he had   any recent weight loss. He’s alert and oriented. I put a saline lock in his wrist. Which flushes fine   he voided 250 of clear yellow urine. He is NPO . his antibiotioc has not been given, but had two albulterol nebulizer treatments. Check the MAR for his med. We did ABGS blood alcohol , cbc, chest ray, chem and metabolic profile, urine analysis and culture and of his sputum. They’re all pending. This is the end of my report.

Identify three priorities noted during report and state an action plan for these priorities.

Answer 1

The three priorities are

• The increased respiratory rate, decreased breath sounds are warning signs for some serious health issues.This gas to be addressed by treating the underlying cause like infection, secretions in lungs.Antibiotics can be administered, Expectorant can help to excrete the secretion. Bronchodilators, corticosteroids to relieve wheezing
• To reduce the body temperature to normal .This can be done by administering antipyretics.
• Neurological examination to rule out the cause for unconsciousness .
• Assess for any signs of fracture as patient walking on the floor