History
Vitals
Labs
Orders
Notes
65-year-old male, admitted yesterday for COPD exacerbation. Long-standing severe COPD, 40 pack-year smoking history (quit 5 years ago), former coal miner. DNR/DNI status confirmed on admission. Family present and supportive.
BP 138/82, HR 92, RR 22, T 37.1 C, SpO2 91 percent on 2 L nasal cannula. Time of measurement not documented in the handoff note.
WBC 14.2 (high), Hgb 13.4, BMP within normal limits, ABG pH 7.35, PaCO2 52, PaO2 64, HCO3 28. Time of ABG draw not documented in the handoff note.
Prednisone 40 mg PO daily; azithromycin 500 mg PO daily; ipratropium-albuterol nebulizer every 4 hours; oxygen 2 L NC titrated to SpO2 88-92 percent; full diet; out of bed as tolerated; pulmonary rehab consult.
Off-going RN handoff note: "Client is DNR/DNI, family at bedside, on standard COPD bundle. Will continue current orders. Please call respiratory therapy if breathing changes."