Nursing Triage

Spoken with: Mrs. Jane Doe, the patient's daughter. Introduced self, role & reason for call: I introduced myself as Nurse Emily, a community nurse, and explained that I was calling to discuss Mr. John Doe's recent health concerns and to provide guidance on his care. S: Mr. John Doe, aged 78, has been experiencing increased shortness of breath and fatigue over the past week. His daughter is concerned about his ability to manage daily activities. B: Mr. Doe has a history of chronic obstructive pulmonary disease (COPD) and hypertension. He was recently discharged from the hospital following an exacerbation of COPD. A: Upon assessment, Mr. Doe appears to be in mild respiratory distress with audible wheezing. His oxygen saturation is 92% on room air. R: Advised Mrs. Doe to ensure Mr. Doe uses his prescribed inhalers regularly and to monitor his oxygen levels. Recommended a follow-up appointment with his GP within the next week. Worsening advice given: Instructed Mrs. Doe to seek immediate medical attention if Mr. Doe's breathing worsens or if he experiences chest pain. OTHER RELEVANT INFO: Mr. Doe has a history of non-compliance with medication, which should be addressed in future consultations. Property access: No known barriers to accessing the property. Animals: There is a small dog at the property, which is friendly and poses no risk. Social: Mr. Doe lives with his daughter, who is his primary caregiver. They have a supportive family network nearby. BMI / build: Mr. Doe has a BMI of 28, indicating he is overweight, which may contribute to his respiratory issues. Patient cognition: Mr. Doe is alert and oriented, with no cognitive impairments noted. Other risks: Environmental risk includes exposure to secondhand smoke, as his daughter smokes inside the home.