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Original Question

For this assignment you must write a narrative, just as you would on a PCR. Scenario: You have been assigned to orient a newly hired paramedic, Mike, who graduated from paramedic school 7 months ago. Your focus today has been on geriatric emergencies, because your territory provides service to six nursing homes and assisted-living facilities. Your unit is dispatched to one of the smaller community nursing homes for a sick person. Upon arrival you are escorted to the day room where the residents spend most of their time. A nurse sitting next to a patient seated in a wheelchair by the window waves you over. She introduces you to Mrs. Howard, a frail, 86-year-old widow. The nurse explains that Mrs. Howard has been running a low-grade fever since last evening and is not acting like her normal self. The physician has requested that she be transferred to the hospital to be evaluated. When asked how she is feeling, Mrs. Howard slowly turns her head and replies, “not well.” Patient appears to be a frail, weak, elderly woman. She is alert and her airway is open and clear. Her breathing seems adequate and is non-labored. Pulses are strong, rapid and irregular. Recognizing an opportunity to complement your earlier review of elderly emergencies with hands-on experience, you ask Mike to begin a physical exam while you obtain a set of vital signs. The nurse caring for your patient is new to the facility and is not very familiar with her. She is able to tell you that your patient has a history of atrial fibrillation, heart failure, diabetes, and hypertension. She is currently prescribed digoxin, pioglitazone (Actos), enalapril (Vaseretic), and ezetimibe with simvastatin (Vytorin). While you are speaking with the nurse, another patient approaches you and sets her hand on your patient’s shoulder. She introduces herself as Mrs. Jessup, a good friend of Mrs. Howard. She tells you that it is normal for them to go for a walk every night after dinner. However, they have not walked for the past couple of evenings because Mrs. Howard has been feeling weak. She also volunteers that Mrs. Howard has not been eating much the past few days. Mrs. Howard brushes off her friend’s concerns. You ascertain from Mrs. Howard that the last meal she had was a bowl of soup yesterday at lunch. Vital signs: Patient is alert. Pulse 110, strong and irregular. BP 168/94. RR 22, regular. Skin is hot, pink, dry. SaO2 is 93% on room air. After gathering the information from the nurse and Mrs. Jessup, you ask Mike what he found during his physical exam. He tells you he found the patient to have signs of dehydration as evidenced by tenting of the skin and dry mucous membranes. He also noted diminished breath sounds bilaterally with crackles at the right base, an elevated irregular heartbeat, and an oral temperature of 102°F. He asks what treatment you would like him to give. You ask your partner to establish IV access so you can administer fluids to help with the dehydration and fever. He successfully inserts a 20-gauge needle in the left hand. Supplemental oxygen is administered via nasal cannula at 3 L/min, and the cardiac monitor is applied. Vitals signs at 11 minutes into the call: Vital signs: Patient is alert. Skin is pink, hot, dry. Pulse 106, weak and irregular. BP 164/92. RR 22, regular. Skin is hot, pink, dry. SaO2 is 98% via N/C at 3L/m. ECG shows A-fib. Pupils equal and reactive. Blood Glucose 178 mg/dL You place your patient on a stretcher in a semi-Fowler’s position and move her to the ambulance. While en route to the hospital, she begins to complain of a being a little winded. A reassessment reveals no changes in her status. Your partner suggests administering a nebulizer treatment of Combivent (ipratropium and albuterol). A nebulized Combivent treatment is initiated. A report is called en route to the emergency department, and no further orders are given. Write your narrative to appropriately describe the treatment and care of this patient using the CHART or SOAP style of narrative.

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