Summary Novel Coronavirus Disease (COVID-19) Part II: Admission to MedSurg

SBAR Handoff to MedSurg Nurse: SBAR Handoff to MedSurg Nurse: Assessment: Most recent vital signs: • T: 100.6 F/38.8 C (oral) • P: 112 (regular) • R: 18 (regular) • BP: 142/84 MAP: 103 • O2 sat: 93% 2 liters n/c RELEVANT body system nursing assessment data: GENERAL SURVEY: Appears anxious, body tense and is sitting upright in bed RESPIRATORY: Breath sounds fine dry crackles bilat. with diminished aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, non-labored respiratory effort, episodic non-productive cough RELEVANT lab values: • WBC: 3.5/ Neuts: 84%/ Lymphs: 11%/ Bands: 5% • Creat: 1.10 • Influenza: Neg/ COVID-19: Pos/ Lactate (Ven): 2. How have you advanced the plan of care? I have maintained strict contact and droplet precautions and have been closely monitoring his vital signs and respiratory status. Patient response: John understands his current condition and his questions have been answered. He presented to the emergency department on room air and was 92%, but his O2 sat dropped slightly in the last hour to 91%. He was placed on 2 L per nasal cannula and his O2 sat has been consistently 93% with no shortness of breath at rest. INTERPRETATION of current clinical status (stable/unstable/worsening): His current condition is stable.