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Mr. Fredrick Johansson

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cathy wojtan

on 28 September 2016

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Transcript of Mr. Fredrick Johansson

Mr. Fredrick Johansson
How priortize care
-A
-B
-C
-know short of breath, O2, breath give ventolin, IV, blood cultures, antibiotic, blood work
CXR
Physican orders
-fluid
-broncho dilator
-cultures
-blood thinners
-bp meds
-physio
-AAT avity as tolerated
-DAT diet as tolerated
-O2 to keep O2 sat over 90%
-IV NS 100 cc
-ceftriaxone (antibiotic)
-ventolin atrovent nebulizer
-vasotec (BP0
-heparin
-STAT CXR
-acetaminphen
-CBC with lytes bun creat lft
-blood cultures
-ABG
-prednisone
What should we assess?
Interventions
O2
pursed lip breathing
positioning
OLDCARTS
O: onset
L: location
D: duration
C: charateristics
A: aggravting
inspection: tripod, barrel chest, clubbing

His Story
65, admittted to medical floor with COPD exacerbation. Etiology to be determined. Past medical HX of HTN,which has been well controlled by enalapril past 6 years. Appears cachetic man who is SOB at rest, productive cough with rust coloured sputum, right side chest pain, fever/chills. 2 packs of per day. Complains poor sling poorly and lately feels tired most time. Currently having difficulty speaking. Not been eating or drinking well

-what to do: ABCD
-airway: is airway patent, difficulty speaking but still able too. Look for potential obstruct er like mucus, vomit. If he does than create airway
-breathing: assess resp rate/ dept rhythm/ accessory muscle use, quick listen, SpO2. What to expect sounds with copd (interventions, positioning, coached breathing, O2 (venturi mask can deliver exact amounts), broncho dilators, IPAP, incubation & ventilation)
-circulation: assess skin colour, temperature, turgor, cap refill, pulse, blood pressure. Interventions (positioning, fluids, drugs (dopamine if low BP), address underlying cause)
-disability: AVPU: alert, responds to verbal stimuli, Painful stimulu and unresponsive. Coma scale assessment
Additonal subjective data ie OLDCARTS, deffered ashe client is in respiraotry distress and difficulty speaking
FINDINGS:
-airway: patient, able to cough up rust coloured sputum
breathing: RR: 28, regular, mderate effort with accessory muscle use note. Decreased air entry t/o crackles in RLL SpO2 86%
-circulation: skin turgor poor, BP high
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