Location: Inpatient medical-surgical unit
Report from ED nurse:
Situation: Christopher Parrish is an 18-year-old male who presented to the emergency department (ED) overnight for respiratory distress and increased work of breathing. He is currently on 2 liters of oxygen via nasal cannula.
Background: Mr. Parrish was diagnosed with cystic fibrosis as an infant and has had frequent previous hospitalizations. He reports shortness of breath, fatigue, and an inability to clear secretions. His oxygen saturations were 85-87% on room air when he arrived in the ED.
Assessment: Mr. Parrish is awake and alert. He is afebrile. His heart rate and rhythm are regular at 80-85/min. Breath sounds evidence coarse crackles in the bases, with a respiratory rate of 24/min. He has maintained oxygen saturation levels at 94-97% with oxygen at 2 L/min via nasal cannula. He is a bit pale. He has airway congestion and a loose, productive cough. His blood pressure is 118/78 mm Hg. He reports tenderness in the chest and back. His regular diet is high calorie, high fat, but he states he has not had much of an appetite the past few weeks. He has ordered some breakfast.
Recommendation: Mr. Parrish is due for vital signs and a thorough respiratory assessment. Please also provide patient education on coughing and deep-breathing exercises. We’ll do the admission assessment later.