Question

Hand off report using SBAR. Filling out the missing information,nursing intervention and major issues with regards to GI bleeding with history of ETHO subtance abuse.

Scenario:You will give the Handoff Report to the nurse working a 12 hour night shift (for this assignment your handoff report will be given to the Instructor).
******Case Scenario – Patient Profile******
You have been working a 12 hour day shift providing care for Mr. Tim Behari, a 35 year old male admitted yesterday after experiencing GI bleeding.
Subjective Data
 History of ETOH substance abuse
 Restless during the night, more restless this morning
Objective Data
 Vital signs at 0600: T – 36.3 °C, P – 96, R – 18, BP – 130/86, pulse oximetry – 96 %
 Current Hgb is 86
 NG tube connected to continuous low wall suction, draining dark reddish drainage
 Intake and Output Record - Data from Night shift at 0600
o Intake:
 PO = 0
 IV = 600
 0.9% NS = 50
 Transfusion = 50
o Output:
 Voided = 525
 NG = 100
Collaborative Care
 IV D5/0.9 NS with 10 ml MVI in 1000 ml infusing at 100 ml/hr into right forearm (RFA) #20 g
 IV site #18 g LFA for blood administration
 Give two units of whole blood today
o #1 – is infusing and should be complete by 0900
 Hemoglobin and hematocrit in the morning
 V/S Q4H
 NPO
 BRP with assistance only
 Monitor for seizure activity
Medications
 Famotidine 20 mg q12h IVPB 1000-2200
At 1000 Tim is anxious, restless, and pulls out the NG tube. VS are: P – 100, R – 26, BP – 146/90. He vomits 20 ml bright red fluid.