Question

Marcella Schmidt (M.S.) is a 73-year-old, widowed female admitted to the hospital after a right hip fracture sustained when she tripped and fell in a parking lot. She had open reduction and internal fixation of her right hip 24 hours earlier. Her medical history indicates that she is in good health, with no other medical diagnoses. She is employed part time at the community library. She is allergic to penicillin and states she got hives all over her body when she took it for strep throat several years ago.

M.S.'s vital signs are T 36.6° C (97.9°F ), P 80 and regular, R 18 and unlabored with an SpO₂ of 97% on 2 L oxygen via nasal cannula, and BP 140/80. She ambulated to the bathroom twice with assistance but grimaced while walking. She transferred from bed to chair with assistance to eat lunch. The physical therapist worked with her on ambulation during the afternoon. She indicates that she is anxious to get moving so she can go home.

Her right hip incision is well approximated, without swelling or excessive redness, and there is no drainage on the dressing. She rates her pain at 7/10 and states that she has “sharp pain that shoots from my hip to mid-calf when I move.” She received oral hydrocodone 5 mg/acetaminophen 500 mg at 0800, 1200, and 1600. At 45 minutes after being medicated she reported pain of 3/10. The nurse responsible for her care on the 12-hour day shift needs to document care according to facility policy, which mandates the SOAPIE format.

Question 1

Develop a SOAPIE note for M. S.

Question 2

What information is important to share with the nurse who will be responsible for M. S.'s care on the next shift?

Question 3

The nurse needs to call the PCP to renew M.S.'s pain medication. Develop an SBAR report for this call.

Answer 1

#. SOAP note :-

S - patient complained of pain

O - As the patient had discomfort due to pain and expressed 7/10 on pain scale , objective is to reduce pain and provide comfort .

A- Assessed the pain using pain scale ,it was 7/10.

P - To provide analgesics to the patient to relief her from hip pain .

#. The information that is important to share with the nurse who will be responsible for M. S.'s care on the next shift is about her pain and what all analgesics is she getting and when was her last dose of pain medication . This is to prevent addiction .

#. SBAR :-

S- M.S. has severe pain at her surgical site and prolonging to the calfs

B- She had an ORIF surgery of her hip 24hrs before.

A- I think we need to renew her pain medication

R- I need you to come and renew the pain medication