patient is at room 205 andwas admitted with fractured right tibia and 1 day post

ID: 124944 • Letter: P

Question

patient is at room 205 andwas admitted with fractured right tibia and 1 day post Op. Male patient. No age. He has a cast on and he has been quiet most of the evening. He just started coughing and experiencing shortness of breath. He has a history of asthma. Nurse assessment noted with positive wheezing. Pulse is 90, temperature is 98.8, Respiration is 28, BP is 140/88, Po2 is 92 %. Pain level is 3/10.

Based on the following Case Scenario: 1. Complete a comprehensive end of shift Handoff Report using the SBAR tool. Your Handoff Report/SBAR is to include a complete head to toe assessment of the patient using all the information provided in the Case Scenario. DO NOT make up information – use only the information provided in the Case Scenario. (5 points) 2. Then answer the following questions, taking the information from the Case Scenario for the assignment. You may need to “make up” some information to answer these questions. (10 points) 1. What are the major issues in the case scenario? 2. What information is missing from the Case Scenario? 3. 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. Use SBAR Chart to answer this question.

Explanation / Answer

Name:unknown

Age:unknown

MALE patient

Room 205

Diagnosis :fractured right tibia

Post op day: 01

Has cast over right tibia.

Relevant past medical history :Asthma

Present complaint:cough and shortness of breath.

Present symptoms :wheezing

Vital signs:

Monitor vitals continuously mainly saturation.

Oxygen therapy.

Monitor the patient for distress.

Elevate head end of the patient.

Remove all aggravating factors causing wheezing.

Inform physician if patient's condition worsen.

If doctors recommend to give any brochodilators and anti-inflammatory drugs, administer the medicines.

S-SITUATION