Exacerbation
Randal Camus
Age: 75Weight: 100 kgLocation: Emergency Department (ED)
Background
Patient History
PNCI® Learner
Past Medical History: Longstanding history of emphysema. Acute
myocardial infarction 12 years ago. Had an upper respiratory infection
about two weeks ago
Allergies: PenicillinMedications: Takes “some heart medications” but
does not know the names, nor can he describe the
pills due to his severe shortness of breath Code Status: Full code
Social/Family History: Married with grown adult children. Wife did
not arrive with him as she is waiting for their son to pick her up and
bring her to the hospital. Patient smokes at least two packs of non
filtered cigarettes per day
, Handoff Report
Situation:The patient is a 75yearold male who was brought into the
emergency department (ED) from home complaining that his breathing
got worse the past few days. He uses oxygen at home, and he was
sitting in his recliner with the oxygen in place at a flow rate of 2 liters
per minute by nasal cannula and smoking when the paramedics arrived.
He reports he also takes “some heart medications” but does not know
the names, nor can he describe the pills due to his severe shortness of
breath.
Background:Longstanding history of emphysema and a previous acute
myocardial infarction 12 years ago. States he had an upper respiratory
infection about two weeks ago. Despite his longstanding COPD, he
continues to smoke two packs of nonfiltered cigarettes per day at a
minimum.
Program for Nursing Curriculum Integration (PNCI®) 1
© 2012 CAE Healthcare, Sarasota, FL v.5
Chronic Obstructive Pulmonary Disease
Exacerbation
PNCI® Learner
Handoff Report Continued
Assessment:Vital signs: HR 134, BP 160/96, RR 40 and labored, SpO2
has been 83% on room air, Temperature 37.6C General Appearance:
Appears fatigued and older than stated ageCardiovascular: Sinus