Question

Write a Situation , background, assesment, reccomendation report (SBAR) / Shift report on skin integrity to next shift RN for 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

SITUATION

I am concerned about the poor coping mechanism of the patient by showing off frustration and with lack of physical activity and participation in physical therapy.He is waiting for the insurance claim approval to be shifted to rehabilitation center.He has pizza chops and soda in most part of his meals.

BACKGROUND

Curtis Jones 22years/M with history of spinal injury due to diving into pool.Has underwent Appendectomy and fractured wrist about 5 and 6 years respectively in the past.His vitals are stable.

ASSESSMENT

I thinks he unstable to handle his frustration, a healthy diet plan has to be done.The risk for injury is more due to his lack of mobility and physical therapy

RECOMMENDATION

I request you to provide him psychological and emotional support to come out with the problems

To establish a therapeutic communication

Position every second hourly to ensure relieve pressure and preventing sore

Therapeutic massage can be done to improve blood circulation

Assess the vital signs especially his pulse to monitor his overall condition and progress.