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Richard Trottier is a 53-year-old man on a medical-surgical floor who was admitted for severe difficulty breathing related to COPD. Mr. Trottier was treated for his respiratory symptoms upon admission to the emergency department and his breathing was stabilized before he was admitted to the medical-surgical floor. In this simulation, you will visit Mr. Trottier during your hourly rounds and assess for changes in his status. Patient check-in : Hard to breathe. Can’t take a full breath. Breathing fast. History of Present illness: it started a couple minutes ago. Nothing triggered this attack. Sometimes it’s bad after he smokes or walk too long. He uses oxygen for a couple of years now. He always feels like he has to cough. It’s the COPD. He need help breathing. He think he needs more oxygen. He asked for help. He said the name of his medication are on the chart. It is wet, but it never clears up. It always feels like you need to cough. He is not in pain. His chest feels heavy but it doesn’t hurt. The cough is wet, but it never clears up. I always feel like I need to cough. Patient is scared because he is having trouble breathing. No Respiratory Issues Aside COPD. No medication allergies. Because of the time, it isn’t worse right now than usual. He coughs up phlegm. Medication does help. It seems to feel worse now than normal, but it’s usually tired every day. No Respiratory issues in the past everything tied to COPD. He cough up phlegm. He feels worse now than normal but he’s usually tired nowadays. He’s feeling stressed out. He’s having trouble breathing. He lost a few pounds when he had pneumonia, though he’s always skinny. He said he is not healthy, he misses the feeling. He is worried he can’t catch his breath and his heart is racing. He said has COPD, a cough that doesn’t go away. In the last few minutes he started having trouble breathing. He had to breathe quick to breathe at all. He chest feels so heavy. His rescue inhaler usually helps to treat symptoms. If he is up and about too long he coughs more. Laying down makes it worse. His symptoms got worse right before i came in. He was diagnosed of COPD around 5 years ago. Patient said is bad right now, he is having difficulty breathing. Patient is a smoker and smokes throughout the day since he was teen. He has used Spirometry before. He said it is a fight everyday with COPD. He started experiencing the symptoms this week. His difficulty in breathing started few minutes ago. He is breathing fast and will rate his breathing a 10. He uses his everyday inhaler, it has a corticosteroid and he also uses a rescue inhaler. Patient is pleading to be helped with breathing. His wife helps him with the medication. She also smokes. There is family history of health problems smoking related, heart issues, stroke, COPD, Cancer. Review of system: no chest pain, though it feel so heavy. It doesn’t usually feel like this, but right now, it’s pretty light-headed. Now having nausea and Vomiting. It worse now normal. But i am ususally tied nowadays. No fever, no night sweety. Sleep will be better. I cough going to sleep. I wake up coughing. He feel light headedness.He doesn’t have pain. He just feels so heavy though. No skin disorder. He has high blood pressure. No joint pain, no swelling. He has palpitation Vital Signs, BP: 144/80mmHg, MAP: 101.3mmHg, Heart Rate:104 bpm, Respiratory Rate: 26 bpm, SpO2: 89%, Temperature: 37.1°C Checked Oxygen Machine. Flow meter is on 2 liters per minute and tubing is connected to the flow meter. Auscultated breath sounds: Adventitious breath sounds in some area such as stridor Auscultated heart sounds, S1 and S2 audible with no extra sound. General assessment: Patient appears uncomfortable or is presenting visually with acute distress or illness. Inspected chest. AP diameter is abnormal. During breathing, patient exhibitss intercostal extraction and excessive use of accessory muscles. Skin: Color of Arm, chest and face is consistent with ethnic background Inspected hands and arms, and ankles and feet. No visible abnormality findings found in any extremities. As a nurse after a comprehensive assessment. Give a comprehensive subjective and objective data

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