Obstructive pulmonary diagnosis

A 66-year-old female client with a diagnosis of chronic obstructive pulmonary disease (COPD) is admitted to the health care facility. The client gives a history of working in a factory for 35 years and that she thinks the chronic obstructive pulmonary disease was caused by inhaling the fumes from the machines she worked with. Her home is near a major highway that is always congested. The client appears well nourished, does not smoke, and only drinks a glass of wine on social occasions. She has recently retired and is hoping to spend time with her grandchildren. Her concern is that, for the past few days, she has been having difficulty breathing and that she has been coughing but it is nonproductive. She has also felt more tired than usual. At first, she thought it was a cold or the flu but became worried when her chest started to hurt each time, she took a deep breath. Vital Signs on admission: BP 126/82, HR 90, RR 26, Temp. 98°F (36.7°C), Pulse Ox 93%.

You are the nurse caring for this patient. On your mid-day rounds, you notice the following: Vital Signs: BP 100/76, HR110, RR30, Temp 101.3F, Pulse Ox 92%.

You determine that you need to call the physician and prepare an  Identify, Situation, Background, Assessment and Recommendation.(ISBAR) communication form.