SBAR ATI UTI - Sbar ATI UTI PDF

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Sbar ATI UTI...

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Situation: Daniel White is an 81-year-old male. He came in today because he was having difficulty urinating and dysuria. Background: Mr. White has hypertension, high cholesterol and gastroesophageal reflex. He has had no prior surgeries and has NKA. He lives with his son and he is a widow his wife died 20 years ago. Mr. White is 185 pounds and 70 inches tall. He is currently taking metoprolol 50mg daily for hypertension and atorvastatin 20mg a day for high cholesterol, famotidine 20mg a day for gastroesophageal reflex and aspirin 81mg daily. Assessment: Mr. White is alert and orientented his vitals are as follows from previous clinic: bp: 114/68, temp 99.4, pulse 92, respirations 18.He is currently taking metoprolol 50mg daily for hypertension and atorvastatin 20mg a day for high cholesterol, famotidine 20mg a day for gastroesophageal reflex and aspirin 81mg daily. He came to the office because he was having difficulty urinating and reported dysuria. His vitals at the current hospital are as follows as of 0900: temp; 100.6, pulse: 92, respirations: 20, BP: 100/56, 02: 95% on room air, pain at a 9 out of 10. Recommendation: Vital signs q4h. Administer 0.9% sodium chloride 10mL flush IV lock q12h and PRN. Administer 0.9% sodium chloride 1000mL infuse at 125mL/hr continue until discontinued. Insert indwelling urinary catheter. Monitor I&O. Chest x-ray and blood culture, CBC and urinalysis. Withhold morning dose of metoprolol today 04/15/21. Medications: Lipitor 20mg PO every evening, Digoxin 0.25mg PO daily, Pepcid 20mg PO daily, ASA 81mg PO daily. PRN medications; Tylenol 650mg PO PRN q4h for fever over 110F, Motrin 400mg PO PRN q6h mild to moderate pain, Morphine sulfate 2mg IV push PRN q4h for severe pain, Zofran 4mg IV push PRN q6h nausea. Continue to monitor I&O and pain. Provide education about infection and hypotension and medications....