Question

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 • Intake:  PO = 0  IV = 600  0.9% NS = 50  Transfusion = 50 • 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. 1.

1. Based on the following Case Scenario, complete a comprehensive end of shift hand off report using the SBAR format. In your report include:

a. The major issues of the case scenario

b. The information missing from the case scenario

c. As the nurse taking care of the patient, what actions did you take?

Include this information in the appropriate section of the SBAR for your Handoff Report.

2. You may need to “make up” some information to complete the chart and answer these questions. Major issues Missing Information Nursing Actions Taken