Question

- Write a SBAR / Shift report on skin integrity to next shift RN on this patient:

Curtis Jones is a 22 year old male patient who was admitted to the medical surgical unit about 1 month ago after suffering a spinal injury from diving into a pool. As a result of the spinal injury he has lost control of both of his lower extremities. He is waiting on clearance from his insurance company for transfer to a rehab facility. Over the last few days he has become frustrated with his length of stay and has not been participating in physical therapy or getting up to bedside chair. He is able to use a urinal to void, and only needs help with the washing of his back. He requires 1 assist to move to chair, when compliant. He has been eating pizza, chips and soda for most meals.

Vital signs: T: 97.1. HR 61 RR 16 BP 107/76 SPO2 100%

Time in the scenario is 7am.

Past Medical History

          Appendectomy 5 years ago

              Wrist fracture 6 years ago

             

Home Medications:

          None

SOCIAL History:

          Recent college graduate

              Lives with parents in childhood home

½ pack per day smoker

         

Answer 1

SBAR REPORT:-

SITUATION:-

Patient Name:--Curtis Jones Age:-22 years Sex:- Male Unit:-Surgery Time:-7 am

Reason for admission:-Patient was suffering from a spinal injury from diving into a pool.

BACKGROUND:-

Patient was admitted to surgical unit after suffering from a spinal injury from diving into a pool about 1 month ago.As a result of spinal injury he has lost control of both of his lower extremities.He had past medical history of Appendectomy 5 yrs ago and wrist fracture 6 yrs ago.He is a recent college graduate and lives with parents in childhood home.

ASSESSMENT:-

BP:-107/76 HR:-61 RR:-16 Temperature:-97.1 SPO2:- 100%

Changes seen in patient conditions:-

- He is able to use a urinal to void urine.

-He only needs help with the washing of his back

- Eating pizza,chips and soda.

RECOMMENDATION :-

- 1 assist should be provided to the patient to move his chair when complaint.

- Patient wants his insurance company for transferring him to a rehab facility .

- He needs counseling as the patient has become frustrated with his length of stay and not able participate in physical therapy. He should consult a Counselor .