Novel Coronavirus Disease (COVID-19) Part II: Admission to MedSurg Unfolding Reasoning

Name/age: John Taylor is a 68-year-old African-American male BRIEF summary of primary problem: He presented to the emergency department because he felt crummy; complaining of a headache, runny nose, feeling more weak, “achy all over” and hot to the touch and sweaty the past two days. When he woke up this morning, he no longer felt hot but began to develop a persistent “nagging cough” that continued to worsen throughout the day. He has difficulty “catching his breath” when he gets up to go the bathroom. Background: Primary problem/diagnosis: positive for COVID-19 RELEVANT past medical history: hypertension and type II diabetes Code status: Full code Assessment: Most recent vital signs:  T: 100.6 F/38.8 C (oral)  P: 112 (regular)  R: 18 (regular)  BP: 142/84 MAP: 103  O2 sat: 93% 2 liters n/c RELEVANT body system nursing assessment data: GENERAL SURVEY: Appears anxious, body tense and is sitting upright in bed RESPIRATORY: Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic non-productive cough RELEVANT lab values:  WBC: 3.5/ Neuts: 84%/ Lymphs: 11%/ Bands: 5%  Creat: 1.10  Influenza: Neg/ COVID-19: Pos/ Lactate (Ven): 2.1 How have you advanced the plan of care? I have maintained strict contact and droplet precautions and have been closely monitoring his vital signs and respiratory status. Patient response: John understands his current condition and his questions have been answered. He presented to the emergency department on room air and was 92%, but his O2 sat dropped slightly in the last hour to 91%. He was placed on 2 L per nasal cannula and his O2 sat has been consistently 93% with no shortness of breath at rest. INTERPRETATION of current clinical status (stable/unstable/worsening): His current condition is stable. Recommendation: Suggestions to advance the plan of care: John will require ongoing monitoring and assessment of his vital signs and respiratory status to identify changes if he begins to decline. J