Case study
sophia4
PatientPreparationandcasestudySBAR1.docx|
MN West AS Patient Preparation/Case Study 5 pts |
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Room: |
Name: |
Age/Sex: |
Surgical Day: |
Admit Date: |
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Code:
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Allergies: |
Isolation: |
Diagnosis: |
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Activity: |
PMH:
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Vitals: |
O2 |
Pain |
BS |
Medications Time:
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Diet: % Eaten: |
Diagnostics: |
Fall Risk: |
Last BM: |
Report/Notes: |
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IV: |
Labs: |
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Start Date:
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Fluid and Rate:
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Change Date:
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Intake: Total for Shift________ IV: PO: |
Therapies: PT OT RT |
Treatments: |
Immunizations Status |
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Output: Total for shift ________ Urine: Drains: Emesis: |
Education Needs: |
Health Promotion |
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Pre-Clinical Nursing Assessment: (from the client chart) 5 pts
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Neuro:
Pain Assessment:
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Cardio/Tele
Edema
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Resp:
Lungs/O2: |
GI:
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GU/Repro:
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Behavioral Health: |
DVT Prophylaxis:
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Skin:
Braden Score: |
Notes: |
Current Nursing Assessment: (during this shift) 5 pts
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Neuro:
Pain Assessment:
Pain interventions:
Pain Reassessment:
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Cardio/Tele Assessment:
Edema
Vitals:
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Resp: Assessment:
O2:
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GI: Assessment:
Last BM:
Intake:
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GU/Repro: Assessment:
Output: |
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Behavioral Health: |
DVT Prophylaxis:
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Skin: Assessment:
Wound/dressing:
Dressing Change:
Braden Score:
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Misc: |
Pre-Clinical Prep-Pharmacology: 10 pts
List each medication you will administer this shift and PRNs in last 24 hours (10 pts)
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Medications: Generic/Trade , Route, dosage, Time |
Pharm. Class: |
Mechanism of Action In OWN WORDS: |
MOST Common Side Effects: |
Nursing Responsibilities: Include assessments needed and special administration instructions |
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Client Name: __________________ Age: __________y/o M/F Admitted: ________Room # _______Doctor _________ FULL CODE/DNR 5 pts
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S Situation |
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B Background |
PMH: Dm / CHF / HTN / CAD / PCI / Liver dz / PVD / GERD / COPD / Asthma / CKD / ERSD / Smoker Drug Abuse / Psych / CVA / Dementia / Hypothyroid / CA /_________ |
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Tests: MRI / X-ray / CT/ Echo EF: ____ / Endo / US / Cath Results of tests: |
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A Assessment
Contact: MRSA C – Diff ESBL Flu COVID Droplet Neutropenic
Need: Urine Cx Resp Cx Flu Swab COVID Swab MRSA Swab
Extras: Daily Weight Strict I &O Fall Risk Observation 1:1 Sitter NPO @ Midnight |
IV # _______ R / L SL Date: __________ Site AC / FA / Hand/ Wrist / UA Central: IJ / PICC / Port / Dialysis |
IVF NS / ½ NS / D5 ½ / D2 NS / LR / Abx IV Rate: _______ ml/hr Drips: heparin / blood / TPN / diabetic / Cardiac |
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Neuro: AXO x _____ / Confused Activity: Up ad lib / 1 / 2 / Bed-rest Walker / Cane Neuro Checks / Restraints / Bed Alarm |
Pain: Level Location: Medication: Frequency: |
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Respiratory O2 @ _____ L NC / RA / NRB / CPAP / BIPAP Trach Breath Sounds: Clear / Diminished / Wheezing / Crackles / Course Cough Productive / non-productive Treatment: Nebs / IS / CPT |
Vital Sign Trends HR Temp BP RR O2
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Cardiovascular SB / NSR / ST / A fib / A flutter / A paced / V paced/ PVC / PACs/ AICD / Murmur / Block Edema none / Gen / Trace / 1+ / 2+ / 3+ Pitting / non-pitting R / L/ Bilateral Arms/Leg Pulses DP Radial Dopplers / +1 / +2 |
VTE Prophylaxis SCDs / Foot Pumps Heparin / Lovenox Coumadin / Xarelto Eliquis / None Needed Needs Other |
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Gastrointestinal Diet Reg / Clear / Full / AHA / ADA / Dysphagia I II III / Soft / Renal / NPO Hypo / Active / Hyper / Nausea / Vomiting / Diarrhea G-tube (LWS / Gravity) / Ostomy Last BM ______ |
Genitourinary Voiding / Foley / Incontinence / Anuria Clear / Cloudy Yellow / Amber / bloody BR / Urinal / Bedside comm / Bedpan Dialysis: M Tu W Th F Sa Sun |
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Musculoskeletal Weakness: RUE / LUE / RLE / LLE Numbness: RUE / LUE / RLE / LLE |
Skin: (Wounds & Dressings) |
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BG Monitoring AC&HS ? Q6h / Q ___h |
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Labs: |
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Drains: Chest Tube / JP / Hemovac / Wound Vac R / L Level: _______ Serosanguinous/Sanguineous |
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R Recommendation |
Scheduled Procedures: Cath / US / Stress / Echo / Dopplers / MRI / CT Consults: PT / OT / GI / Cards / Neuro / Nephro / Wound / Ortho / Psych / Pulm / Surg Discharge to: Home / Home Health / Assisted Living/ Nursing Home/ Rehab Discharge Day: ___________ |
Put it All Together to Think Like a Nurse (complete this during your shift)
1. What data did you collect from the medical record and the patient that is RELEVANT to the nurse? 1 pt
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RELVEVANT Data: |
Clinical Significance: |
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2. Identify data gaps. What did you not find out about your patient that would be useful for their ongoing care?1 pt
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Data Gaps: |
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3. What problems might you see in your patient/identify the most likely problems. Why might you see those problems? Rank them in order of priority. What additional data would be needed relevant to the problem?1 pt
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Patient Problems: |
Why: |
Rank: |
Additional Data Needed: |
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4. Using your identified problems this shift, what is the physical nursing priority and priority interventions to advance the plan of care? 3 pt
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Nursing Priority: |
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Outcome (SMART Goal) |
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Interventions: |
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5. Using your identified problems this shift, what is the psychosocial nursing priority and priority interventions to advance the plan of care? 3 pt
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Nursing Priority: |
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Outcome (SMART Goal) |
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Interventions: |
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6. Education Priorities/Discharge Planning: What educational/discharge priorities were taught to your patient during your clinical day? 1 pt
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Education PRIORITY: |
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Priority Topics to Teach: |
Rationale: |
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Client is an 87 yrs old male
Diagnosis: Pulmonary Thromboembolism
Last Wt: 84.7 kg (186 lbs 11.7 oz)
Code Status: NCB (No code blue)
On admission x-ray did confirm substantial pleural effusion on the left side. This may be contributing to his symptoms of shortness of breath, fatigue and low blood pressure. There were also presence of pulmonary emboli and possible pneumonia, he was admitted for further management of these issues.
