Primary Concern – Admission Diagnosis Acute Respiratory

Primary Concern – Admission Diagnosis Acute Respiratory Failure S- Situation Mr Nguyen presented to the emergency department with shortness of breath, B- Background Mr Nguyen was shrimping 3 days ago. Upon arriving at the dock, he was trying to untangle his shrimp nets that were 25 feet off of the ground. When his leg got caught in a net, it caused him to fall 25 feet, landing on his chest. He was able to get up, refused emergency medical attention, and went home. Mr. Nguyen has a 60 pack/yr smoking history. his only additional history includes a laceration of his leg which required 20 stitches in 1988. A- Assessment Pulse oximetry 89% on RA, and sinus tachycardia with frequent PVCs. Mr. Nguyen’s oxygen saturation continued to drop to 82% NRBM. He was intubated in the emergency department. Etomidate 20 mg IV and Anectine 100Mg Iv were given prior to intubation 30 min ago. Mr. Nguyen currently has a 7.5 cm ETT at 22 cm at teeth, right side of mouth. Vent settings are TV 550, assist control 10 FiO2 55%. ABGs were done prior to transfer to ICU (15 min ago). A chest x-ray was also done after intubation. BMP and CBC results are pending. Mr Nguyen’s daughter is at the bedside. R- Recommendation Review the orders, assess and monitor Assisting with intubation, a plan for the following: Assessment, Diagnosis, Outcomes / Planning, Interventions, Evaluation, Additional Information How will you prepare the patient for the procedure? What equipment will you need to gather prior to the procedure? How will you assist in the procedure? What complications can occur during the intubation and what actions will you take? SCIENCE HEALTH SCIENCE NURSING NUR NUR258

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