SBAR Medsurg 3.0 Real life PDF

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Situation: Janice Jordan age 78 was admitted to the ER on 08/01/2021 for urosepsis. While assessing patient noticed clinical manifestations of heart failure and hypoxemia through signs of distressed breathing and history of CHF. Patient was given 02 via nasal cannula begging with 2 L/min increased 4L/min then to 6 L/min when signs of distributive shock were observed. Background: Mrs. Jordan has experienced increased respiratory distress during the past 2 hr. Since admission, she has received 2,550 mL IV and 100 mL orally. Her urinary output since admission to the medical-surgical unit has been 100 mL. Patient has history of diabetes, CHF. No listed surgical history. Patient has no known allergies. Safety Precaution to consider patient fell out of bed, which caused her to have a hip fracture, she was treated with a Bucks traction because her CHF made her high risk for surgery. Vitals at 0500 were T: 99.4, P: 96, R: 24, BP: 136/76, O2: 91% Vitals at 0700 were T: 99.4, P: 88, R: 22, BP: 128/84, O2: 91% Blood Glucose 0600: 88 Intake Total: IV/IVPB, 2360 Output 0700: 100 via indwelling catheter. Medications: Glyburide 2.5 mg PO with breakfast last taken 0800. Levofloxacin 250mg IV bolus every 12 hours 2100. Also prescribed as needed acetaminophen 325 mg every 4 hours for fever greater than 100 degrees F. Lorazepam 2mg PO every 6 hours for agitation and restlessness. IV therapy 100 mL Lactated Ringers IV at 30 mL/hr. Assessment: Mrs. Jordan is at risk for skin breakdown due to her age, her cardiac condition and her mobility that is restricted due to the placement of Buck’s traction. While assessing the client for skin breakdown a stage two ulcer was observed. Abnormal Findings: ABG’s were taken and recorded pH: 7.28, PaCo2 :35, HCO2: 20. Labs: CBC- Hgb 11.3 g/dl, Hct 33%, WBC-13,000/mm3, BUN 21mg/dl, Albumin: 3.2 mg/dl, cholesterol 255 mg/dL, UA: Cloudy, slight amber, Specific gravity 1.039, protein 2 mg/dL, leukocyte esterase positive, WBC 10, RBS 4-6, RBC Casts Positive Recommendations: Continue monitoring patient’s output, and 02 sat levels, vital signs, and pain level. Ensure the hip fracture does not compromise circulation on the affected side, check pulses, and client's ROM on toes frequently. Vital signs every 4 hours, Routine I&O, insert peripheral IV Cath, foley catheter. Mrs. Jordan showed signs of distributed shock and is becoming septic. 2g sodium diet. Assess pain and condition. Consult with physician once stable condition. Continue to monitor ulcer and dressing changes on site. Request antibiotics for sepsis. Consult with PT for Hip fracture. Discharge procedures once stable....