Question

Can you please provide me end off shift report(handoff report)and nursing concern to this senario and nursing action

the nurse has been working a 12 hour day shift providing care for Mr. O, a 62 year old male who has cellulitis of the right leg. He has a past medical history of angina, hypertension, and DM Type 2.

During Morning Report, you are told: • Mr. O stays in a chair most of the time with his leg elevated • His intake and output are fine, and his vital signs are stable • He has a dry dressing on the right leg and there is no drainage • His saline lock needs to be changed today

Subjective Data • "I am not used to being in bed so much."

Objective Data • Vital signs - T 37° C, P 92, R 22, BP 164/94 • Pain level 0 • Pulse oximetry 98% • Fingerstick blood sugar at 0600 = 6.1

Collaborative Care • V/S Q4H • BRP (bathroom privileges) • Regular diet • Change leg dressing Q shift • Saline lock #22 G angiocath • O2 at 3 l/min np PRN • Elevate leg on pillow • Fingerstick BG QAM at 0600  

Medications • Glyburide 10 mg PO QAM • Verapamil SR 240 mg PO BID • Propranolol 20 mg PO BID • ASA 81 mg PO QAM • Senokot 2 tabs PO QAM • Vancomycin 500 mg IVPB Q6H • Nitro SL 0.4 mg Q5min × 3 PRN for chest pain

During your shift, at 1200: Mr. O returns to bed after having a BM. You note that he is short of breath and his skin is cool and clammy. You assess his vital signs, his radial pulse is 110 and irregular, respirations are 32, and his BP is 170/100. He tells you that he is feeling pressure on his chest. You assist him into bed and place him in High Fowler position.

Answer 1

The patients name is Mr. O, a 62 year old male who has cellulitis of the right leg. He has a past medical history of angina, hypertension, and DM Type 2.

Vital signs - T 37° C, P 92, R 22, BP 164/94 • Pain level 0 • Pulse oximetry 98% • Fingerstick blood sugar at 0600 = 6.1

Medications given :-

• Glyburide 10 mg PO QAM

• Verapamil SR 240 mg PO BID

• Propranolol 20 mg PO BID

• ASA 81 mg PO QAM

• Senokot 2 tabs PO QAM

• Vancomycin 500 mg IVPB Q6H

• Nitro SL 0.4 mg Q5min × 3 PRN for chest pain

The patient has an episode of shortnesa of breath along with cool ,clammy skin with a vitals of pulse is 110 and irregular, respirations are 32, and his BP is 170/100 when he returned to bed after BM . He was feeling pressure on his chest for which he was given High fowlers position to expand lungs and increase oxygen flow , IV fluids were stated ( RL ) , analgesics were given like morphine , antihypertensive were given to control BP . The patient is fine now and is on monitoring every 2hrly