Question

In: Nursing

The nurse is caring for a client who has been admitted to the emergency room with...

The nurse is caring for a client who has been admitted to the emergency room with generalized weakness, particularly on her left side, with a left-sided facial droop, aphasia, numbness, and tingling in her left arm which started two days ago. Pupils are minimally reactive and constricted bilaterally. She does not follow commands. Lower extremities have + 1 pitting edema bilaterally. The client is transferred to the neuro floor but will be discharged home with her son.

  • Using the Situation Background Assessment Recommendation (SBAR) format, provide a hand-off report to the neuro floor RN
  • Identify/describe 3 examples of Indirect and Direct Care for this patient
  • Identify and prioritize 4 area's of safety/risk issues for this client
  • Provide the top 2 nursing priorities for this client in anticipation for discharge planning

Include any discharge teaching

Solutions

Expert Solution

The SBAR (Situation-Background-Assessment-Recommendation) is a technique that facilitates communication between health care members regarding patient's condition.

S = Situation (a concise statement of the patient's problem)

B = Background ( important and brief information related to the situation)

A = Assessment (analysis and considerations of options )

R = Recommendation (action requested/recommended).

Example of SBAR model.

Situation. This is staff nurse anju from emergency. I am calling you about Mr x who is diagnosed with cerebro vascular accident.

Vital signs are blood pressure, pr, hr, rr, spo2, gcs.

Background. The patient is in hospital because he has weakness, aphasia left sided facial droop and constricted pupils. He was apparently well 2 days back.

Assessment. I think the patient is diagnosed with cva. But I am not sure about it. He is deteriorating and requires better care. I have assessed vitals and administered the medications ordered.

Recommendation. Would you come see the patient. Do you want me to do anything specifically before shifting the patient.

2.Indirect care.

Admission and discharge formalities.

Recording

Communication regarding patient condition.

Direct care.

Assisting in hygienic needs.

Administering medications.

Counselling the patient.

4 areas of safety risk.

Risk for fall and injury.

Fisk for aspiration.

Communication problem.

Feeding difficulties.

Priority care

Smash the food well or use tube feeds to prevent aspiration.

Do range of motion exercises.

Test the water temperature with unaffected hand.

Use grab bars, a shower seat, a hand-held showerhead, and a long-handled brush.

Take your medicines exactly as directed.

Come to emergency if you have any symptoms.

Nightingale answered 1 year ago
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