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Shift handover
Identify: Mrs Amity Purple, HRN: 123678, DOB: 19/02/1962
Situation: Amity is a 57 year old Caucasian lady from Darwin. She has been admitted to the CDU medical ward with exacerbation of COPD. She has a 2/7 history of dyspnoea, productive cough and a fever.
Background: Amity lives in a two-story home with her husband. She is independent with her cares. She has a past medical history of: T2DM, smoker (20 per day), HTN, hyperlipidaemia and obesity. No known declared allergies (NKDA). She is obese (BMI 30) and drinks 1 bottle of wine every night.
Assessment: Airway: Own, patent Breathing: RR 26, Sats 89% on RA. Circulation: HR 89 bpm, BP 160/95 mmHg. Disability: GCS 15/15, 2/10 sharp chest pain on inspiration
Exposure: Temp 38.6oC
Recommendations/Read back: Medical orders • Chest X-ray ordered • Administer medications as charted • Pain management • TED stockings and DVT prophylaxis Medication orders
New medications: • Paracetamol 1g PO QID • Ceftriaxone 1g IV BD • Amoxycillin 1g PO TDS Usual medications: • Metformin XR 1gm BD • Simvastatin 20mg OD • Salbutamol MDI 100 mcg PRN • Seretide MDI 1 puff BD
Question Discuss the pathophysiology of the exacerbation of COPD from Shift handover of Mrs Purple
SCIENCE
HEALTH SCIENCE
NURSING
