Question

Case Study: You have arrived at clinical. You receive an assignment for the 88 year old female with a right hip fracture. She was riding with her daughter to their weekly grocery shop when they were in an MVC, she was wearing a seat belt, no LOC. She is post op day 1. Her medications are as follows: Enoxaparin 30 mg SQ daily, Ancef 1 gram/50ml IVPB QSH x 3 doses (she is on dose 3 at 9am), Lisinopril 10 mg po q day, Aricept 5 mg po q day, Metoprolol 12.5 mg po q day, Plavix 75 mg po q day, Atorvastatin 40 mg po q day, Multaq 400 mg bid, senna 8.6 mg bid, miralax 17 g daily, Dilaudid 0.5 mg IVP Q6H prn pain, Percocet 5/325mg Q4H prn pain and pantoprazole 40 mg po 4 day. The night shift nurse was vague but stated she is Ox3, IV to Left hand, 20 gauge, CDI, BBS are clear, Abd soft with + bowel sounds, Drsg to R hip is CDI, incontinent with purewick and pad. Her abnormal labs are as follows: Platelet count <50, Hct 18, Hgb 6, Creatinine 2.4, BUN 25, K 5.2, PMH: A-fib, G5P3, Stents x 3 following a MI in 2010, Cholecystectomy 2009, osteoporosis, dementia, HTN, HLP VS: 106/52, HR 55, RR 14 and shallow, T 99.6, O2 is 92% on room air. When you walk in the room, she complains of pain 6/10. Her lung sounds are diminished to bilateral bases and she is breathing shallow. She is wearing a telemetry monitor that shows NSR. She has adequate bowel sounds, Last bowel movement was 3 days ago and she complains of constipation. She has adequate pulses and neuro checks. Her dressing shows some old bloody drainage about the size of a nickel. Her SCDs are flopped down in the floor. The side rails are not up correctly and the bed is not locked. There is no incentive spirometer to be found. When you question her, she says she is in Walmart and Richard Nixon is president. Her orders are: SCDs, IS QIH while awake, LR @ 75ml/hr, Fall precautions, PT to assess and treat, walker at bedside, bedside commode. Crush meds to applesauce. Write an SBAR as best that you can.

Answer 1

THE SBAR OF THE PATIENT AS FOLLOWS

S(situation)- PATIENT NAME- NA PATIENT AGE-88 YEAR DIAGNOSIS-RIGHT HIP FRACTURE  

STATUS-POST OP DAY 1

THE PROBLEM I AM CALLING ABOUT-THE PATIENT IS BRADYCARDIC.SHE COMPLAINS OF PAIN.THE LUNG SOUNDS IN BOTH SIDES ARE DIMINISHED.PATIENT HAVE URINARY INCONTINANCE AND COMPLAINS OF CONSTIPATION.

THE ASSESMENT DATA AS FOLLOWS- TEMP-99.6 F,BP-106/52 mm hg, RR-14/mt,HR-55/mt and SATURATION-92 percentage on room air.

THE MAIN PROBLEM IS THE PATIENT IS BRADYCARDIC AND URINARY INCONTINANCE

THE LAB VALUES ARE DERANGED AS FOLLOWS-HB-6 gm/dl,s.creatinine-2.4,BUN-25,Serum pottasium-5.2

B(BACKGROUND)-88 YEAR MULTIPAROUS WOMEN(G5P3).THE PATIENT IS SUFFERING FROM DEMENTIA AND A PAST HISTORY OF MI ON 2010.STENTS IN PLACE.SHE HAD PAST HISTORY OF CHOLECYSTECTOMY ON 2009.

A(ASSESMENT)-THE MAIN PROBLEM WHILE ASSESSING THIS PATIENT IS PRIMARLY IS CARDIAC AND PATIENT IS BRADYCARDIAC.SHE HAVE  URINARY INCONTINANCE AND ELEVATED BUN LEVELS.AND HEMOGLOBIN CONCENTRATION IS VERY LOW.PATIENT HAVING HYPERKALEMIA AND PRONE TO DEVELOP SOME CARDIAC ARRYTHMIAS.

R(RECOMMENDATIONS)-

PLEASE COME AND SEE THE PATIENT

THE CARDIAC FUNCTION OF THE PATIENT IS COMPRAMISED.

I THINK PATIENT IS PRONE TO DEVELOP ARRYTHMIAS AND THE HEMODYNAMIC PARAMETERS ARE DERANGED.

I THINK THE PATIENT MUST SHIFT TO CRITICAL CARE UNIT.I HOPE YOUR ADVICE IS NEEDED FOR THIS PATIENT RECOVERY