Nursing Documentation

Reason for Call and Concerns/Alerts: - Patient called due to increased shortness of breath and a persistent cough that has worsened over the past 24 hours. - Expressed concern about potential chest infection due to feeling generally unwell and fatigued. - Alert for history of chronic obstructive pulmonary disease (COPD). Current Status: - Patient reports shortness of breath at rest, rated 6/10 on a visual analogue scale. - Productive cough with yellowish sputum, increased frequency compared to yesterday. - Denies chest pain or fever, but feels cold and clammy. - Oxygen saturation noted at 88% on room air at the beginning of the call, improved to 92% with 2L supplemental oxygen via nasal cannula. - Respiratory rate 24 breaths/min, shallow. Interventions/Care Provided: - Advised patient to sit upright and use prescribed salbutamol inhaler (two puffs). - Instructed on correct inhaler technique and timing. - Encouraged deep breathing exercises and effective coughing techniques. - Arranged for urgent home visit by a community nurse for further assessment and vital sign monitoring. - Provided education on signs of respiratory distress and when to seek immediate medical attention. Observations/Findings: - Patient's voice was slightly wheezy during the call. - Noted use of accessory muscles of respiration audible over the phone. - Patient reported feeling calmer after using inhaler and receiving supplemental oxygen. Plan for Next Shift/Doctor to Review: - Community nurse to visit within 2 hours for full clinical assessment, including vital signs, lung auscultation, and further oxygen therapy adjustment if needed. - Follow up call to patient within 4 hours to re-assess respiratory status and effectiveness of interventions. - Dr. Eleanor Vance to be notified immediately of patient's current condition and home visit plan for review and potential prescription of antibiotics or steroids if indicated after community nurse assessment. - Document all findings and interventions thoroughly in the electronic patient record.