“What is going on with this patient?”
Chief Complaint (what symptoms the patient came to the hospital with):
Patient was involved in MVA going 45 mph and hit a tree.
Diagnosis_Right Ankle Fracture Vital Signs: BP-108/71 P-76 Temp- 98.7 F; O2 Sat 99%
Pain Level___6_________ Where_Rt leg, chest, & rt wrist_______________
Description_Acute, somatic, pain in rt leg, thorax, and rt wrist SBAR Template
Primary MD__Gannu_____________ Code Status (DNR?) N/A (Full code)
ORDER A PLAGIARISM-FREE PAPER HERE
Date of admission__10/6/18____________
“What is the clinical
PMH (Previous medical history including past surgeries)
Diabetes Mellitus, Smoker, Bipolar, Mood Swings, Depression, Heroin Use
“Head-to-toe assessment that I am going to chart into the EMR after I review it with my instructor organized by body system.”
Respiration Rate ______16___________ Lung Sounds_____Clear_____________
Supplemental Oxygen __N/A_______LPM Oxygen Saturations__99%___________
Incentive Spirometry __unknown (I will check EMR next time & collaborate with Respiratory Therapist)
Heart Rate: Regular______________
IVF’s __ Saline Lock__________Rate_ N/A _____________
IV Site_Left mid forearm______________ Start Date_10/6/18_________
Edema (where/rate): rt wrist +1; rt lower limb (unable to assess due to ace bandage & splint)
Pedal Pulses: Strong on left foot, unable to assess rt foot due to ace bandage & splint
Alert and Oriented X4________ or
Altered mental status___ N/A______ Deficits__ N/A_______
Diet Normal______ Last Bowel Movement___10/8/18_________
Assistance eating __no_______ Bowel Sounds__Present x 4_______________
Any Drains present____ N/A________ Accuchecks ___90_________________
Voiding__Yes__________ Foley Catheter__ N/A_______
Description Of Urine unknown___________________________________________
I and O’s
Input ____ N/A_______ Output___ N/A________
Activity _Limited__________ Falls Risk Score_70______ Falls Risk Y
Assistive Devices _Walker______________
ROM _Non-weight bearing right leg, limited ROM
Special Concern’s/Problems/ Scheduled events for the day
Any wounds/ Skin Breakdown Present
Location _Rt lower limb__ Dressing type Ace bandage; unknown dressing type underneath__
Presence of drainage from wound or on dressing (describe drainage characteristics)
Unknown due to splint and ace bandage on right lower limb. No visible drainage through the ace bandage. Ace Bandage is dry and intact.
Any diagnostic tests or procedures scheduled for today? No. SBAR Template
10/6/18 -Head CT: No evidence of intercranial hemorrhage or acute findings within the brain.
10/6/18-XR(Pelvic, Rt Knee, Rt Tib/Fib, Chest) Comminuted fracture of the distal fibula & medial malleolus w/o displacement. Bilateral fracture of the first ribs.
Abnormal Labs from 10/9/18- Hematology: WBC 12.4 (H)(normal 4-11); monocytes 10.7%(H)(Normal 2-8%);Neutrophils# 8.2(H)(normal 1.5-8);monocyte # 1.3(H) (Normal 0.2-1.0) Chemistry: Na 132(L) (normal 135-145);BUN/Crea Ratio 21.0 (H) (normal 10-20)
Physical Therapy_Yes, educated pt on how to ambulate w/o using NWB right leg____
What do you think should be done to help your patient
This is a summary of your shift’s observations that could assist the next shift in planning care for the patient
· Rest. Limit patient mobility, until right leg can bear weight. Eventual use of CAM boot when ambulating.
· Place an ice pack on right lower limb in 20 minute increments 6-8 times/day
· Elevate leg on pillows to help with swelling.
· Compression. Continue with ACE bandage and splint on right leg for support and to ease swelling.
· Continue with incentive spirometer 5-10 times every 2 hours. SBAR Template
· Have patient wiggle toes on right foot often to promote blood flow.
· Continue with physical therapy to learn how to safely ambulate using walker/crutches due to NWB status of right leg.
· ROM exercises for unaffected joints of the body.
· Consult with Social Services and Case Manager. Possible transfer to skilled nursing facility for rehab due to patient’s living situation SBAR Template.
NUR 133 SBAR/Physical Assessment Tool Rubric-
Section Satisfactory Needs
Basic Information All areas addressed Some areas addressed None of the areas addressed
Neurologic All areas addressed Some areas addressed None of the areas addressed SBAR Template
Skin All areas addressed Some areas addressed None of the areas addressed
Head, Eyes, Nose, Throat All areas addressed Some areas addressed None of the areas addressed
Respiratory All areas addressed Some areas addressed None of the areas addressed
Cardiovascular All areas addressed Some areas addressed None of the areas addressed
Gastrointestinal All areas addressed Some areas addressed None of the areas addressed
Genitourinary All areas addressed Some areas addressed None of the areas addressed
Musculoskeletal All areas addressed Some areas addressed None of the areas addressed
Psychosocial All areas addressed Some areas addressed None of the areas addressed SBAR Template
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