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Cardiopulmonary Arrest
PNCI - Learner
Robert Johnson
Age: 60
Weight: 70 kg
Base: Stan D. Ardman
Patient History
Past Medical History: Hypertension well-controlled by medication, hypercholesterolemia and obesity; minor car accident three weeks ago in which he sustained whiplash
Allergies: No known drug allergies
Medications: Lopressor (metoprolol), Zocor (simvastatin)
Code Status: Full Code
Social/Family History: Married with two adult children who live locally; Does not smoke, drink or use illicit drugs
Handoff Report
Situation:
The patient is a 60-year-old male in room 425 on the Orthopedic Unit who is recovering from an anterior-posterior interbody fusion of L4 – L5 performed two days ago. His has had an uneventful recovery. He is in his room eating breakfast.
Background:
Hypertension, hypercholesterolemia and obesity. The hypertension has been well controlled by his medication. He is wearing a soft neck collar for support following a minor car accident three weeks ago in which he sustained whiplash. The patient has no known drug allergies and is awake and alert.
Assessment:
Vital signs: HR 87, BP 128/62, RR 18, SpO2 has been 98% on room air, Temp 37.1oC
Cardiovascular: No telemetry; HR regular
Respiratory: Clear in both lung fields
GI: Advanced to full liquid diet and tolerating it well
GU: Voiding clear, yellow urine
Extremities: Pink, warm and with adequate turgor; Movement is strong in all four extremities (4+)
Skin: Warm and dry; No signs of infection at his surgical site
Neurological: Alert and oriented to person, place and time; pupils equal, round, reactive to light and accommodation; no neurological deficits
IVs: No IV access; saline lock became dislodged during the night and was not restarted as he will be discharged soon
Labs: No labs ordered
Fall Risk: Low-risk
Pain: Well controlled
Recommendations:
Provide a complete

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