PNCI - Learner
Otto Looper
Age: 72
Weight: 70 kg
Base: Stan D. Ardman
Patient History
Past Medical History: Patient had the flu along with vomiting and anorexia for the past week. He also
has a history of hypertension and osteoarthritis.
Allergies: No known drug allergies
Medications: Celecoxib and hydrochlorothiazide
Code Status: Full Code
Social/Family History: Lives alone in a small home without air conditioning. Married daughter visits
regularly. Daughter at the bedside.
Handoff Report
Situation:
This patient is a 72-year-old male who is being transferred from the ED. A diagnosis of rhabdomyolysis
is suspected, precipitated by heat exhaustion. In the ED, an IV was started, an indwelling urinary
catheter was inserted and labs were drawn. He was hydrated with a 500 mL 0.9% normal saline (NS)
bolus. Due to his low urine output, cola-colored urine, altered level of consciousness and pending
labs, he is being admitted to the Medical Unit. Admitting orders have been written and are on the
chart.
Background:
The patient’s daughter found him on the floor of his kitchen this morning dressed in the same clothes
he had on yesterday. He was on his back, incontinent of urine, confused and speaking gibberish. It
is believed that he was lying on the floor most of yesterday, unable to call for help. There has been
an extreme heat wave for the last several weeks. The patient’s home does not have air conditioning.
The patient lives alone and has had the flu, along with vomiting and anorexia for the past week.
It is unclear why or how he fell. According to his daughter, he is in relatively good health but has
hypertension and osteoarthritis. He is alert but disoriented to time and place. He is anxious and
asking for his daughter. He complains of dizziness, muscle pain, cramps and fatigue. He has no
known allergies.
Assessment:
Vital Signs: HR 118, BP 80/60, RR 22, Temp 39.8oC
General Appearance: Anxious, appears older than stated age
Cardiovascular: Sinus tachycardia
Respiratory: Breath sounds clear bilaterally
Program for Nursing Curriculum Integration (PNCI®) Heat Exhaustion 1
© 2009 METI, Sarasota, FL