Question

At the start of the shift, you are assessing an 86 year old patient who is...

At the start of the shift, you are assessing an 86 year old patient who is awaiting surgery for a hip repair after a fall 12 hours ago at home. You are collecting a clean-catch urine specimen, using a bedpan, as part of the preoperative preparation. You observe that when she voids, the urine odor is foul and the urine is cloudy and full of sediment. She reports some urgency but notes that she had urgency before her fall. What assessment information will you document in the chart? What additional information should you ask the patient and what else should you consider? Organize your thoughts into a SBAR communication. Who should you notify and why?

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Answer :

* 86 years old patient awaiting for Hip surgery.

The assessment information is :

* urine odor is foul smell,

* cloudy and full of sediment,

* urgency of urine, it is not there before fall.

These assessment information I should be noted in the chart.

Because these all symptoms includes in " urinary tract infections ".

The additional information like,

* client past medical and surgical history,

* client is having any diabetes mellitus and hypertension ect.

* if client is having any chronic diseases related to heart and kidney, liver ect.

SBAR communication means :

S - situation

B - background

A - Assessment

R - recommendation

Here the client situation is preoperative patient is posted for Hip surgery,

Background information is past medical and surgical history

Assessment physical assessment, psychological assessment.

Recommendations are maintain aseptic techniques after surgery,

Intake adequate fluids to reduce urinary tract infections.

Follow up care.

Urologist consultation I advise for clearance of surgery because client is having as having urinary tract infections.

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