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Ms. RG, 85 year old female |
End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement |
Vital Signs q 4 hours NPO Trach Care q shift and as needed Trach mask to 50% humidified O2 Wet to dry dressing to coccyx q shift Wound culture IV-D5 ½ NS @ 100mL/hour IV-Cefazolin 1g in 100 mL of D5W q 8 hours |
CBC BMP PT, PTT Wound culture Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/ L K: 4.0 mEQ/ L Cr: 1.2 mg/ dL Glucose: 200 mg/ dL BUN: 25 mg/ dL WBC: 6800/ mm/3 Hgb: 11.5 g/dL HCT: 34% PLT: 200000 PT- 18 aPTT: 25 seconds |
Patient had restful shift; needs dressing change to pressure injury on coccyx. Planned transfer back to SNF tomorrow. |
Write an End of Shift SBAR to Oncoming Nurse for the patient above
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Situation:-
End of shift SBAR report
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Situation End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement |
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Background:-
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Assessment:- CBC BMP PT, PTT Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/ L K: 4.0 mEQ/ L Cr: 1.2 mg/ dL Glucose: 200 mg/ dL BUN: 25 mg/ dL WBC: 6800/ mm/3 Hgb: 11.5 g/dL HCT: 34% PLT: 200000 PT- 18 aPTT: 25 seconds |
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Recommendations:- Patient had restful shift; needs dressing change to pressure injury on coccyx. Planned transfer back to SNF tomorrow. Send sample for wound culture |
Ms. RG, 85 year old female End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x...
Ms. RG, 85 year old female End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement Vital Signs q 4 hours NPO Trach Care q shift and as needed Trach mask to 50% humidified O2 Wet to dry dressing to coccyx q shift Wound culture IV-D5 ½ NS @ 100mL/hour IV-Cefazolin 1g in 100 mL of D5W q 8 hours CBC BMP PT, PTT Wound culture Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/...
Ms. RG, 85 year old female End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement Vital Signs q 4 hours NPO Trach Care q shift and as needed Trach mask to 50% humidified O2 Wet to dry dressing to coccyx q shift Wound culture IV-D5 ½ NS @ 100mL/hour IV-Cefazolin 1g in 100 mL of D5W q 8 hours CBC BMP PT, PTT Wound culture Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/...
Ms. RG, 85 year old female End-stage COPD Pressure Injury-Stage 3 PMH s/p right lobectomy x 1 year ago s/p trach placement Vital Signs q 4 hours NPO Trach Care q shift and as needed Trach mask to 50% humidified O2 Wet to dry dressing to coccyx q shift Wound culture IV-D5 ½ NS @ 100mL/hour IV-Cefazolin 1g in 100 mL of D5W q 8 hours CBC BMP PT, PTT Wound culture Diagnostic Test Na: 138mEQ/ L Cl: 90 mEQ/...