Handover and Written Nursing Report
Mr Jason Bilko is an 81 year old male (MRN: 12-34-56, DOB: 01/01/1937) who lives as 1 Soft Street, Chowtown, 4560. He presents to the emergency department on the 03/09/2018 at 1600hrs with chest pain and shortness of breath.
He has had prior admissions to the hospital with Unstable Angina and has a history of multiple falls recently. On arrival, patient denies chest pain but has a resp rate of 32 and a SaO2 of 82% on room air. After you receive handover from the ambulance officers, you do an assessment on Mr. Bilko. You notice that his heart rate is 101bpm, SaO2 88%, BP 138/72, temp of 36.8 and Resp rate of 28.
You document these in his observation chart and commence 6L 02 via a Hudson mask. You complete an ECG and attach the patient to a cardiac monitor-monitoring in sinus rhythm. The ED staff specialist, Dr Lance, reviews the patient and orders a chest x-ray. He reviews the ECG and notes no abnormalities. He inserts an IV cannula and takes blood. He orders IV fluids which you commence.
The patient returns from radiology and Dr Lance diagnosis the patient with mild pulmonary oedema and admits him under Dr Turner. He orders Furosemide 40mg IV which you administer. After you administer the medication, you repeat the observations and document them in the observation chart.
Written Nursing Report
Complete all the required details for your patient in the progress notes attached.
Attachment:- Template.rar