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

Next > < Previous

Related Solutions

The nurse is caring for a client in the emergency room with a chief complaint of...

The nurse is caring for a client in the emergency room with a chief complaint of fever, and cough for the last 3 days. The client has the following data: Client Information Medical Diagnosis Rheumatoid Arthritis, Influenza A Social History Sister in law died of lung cancer Multiple sexual partners in the last year, worked in a factory for 20 years, Exercises one a week Medical History History of Epilepsy, Was treated for Herpes Simplex- 1, and had acute bronchitis...

The nurse is caring for an 88-year-old diabetic client who has been admitted from a long-term...

The nurse is caring for an 88-year-old diabetic client who has been admitted from a long-term care facility for treatment of an infected, stage 4 pressure ulcer. (20 points each) Identify the different stages of pressure ulcers, describing the assessment findings for each of the 4 stages. Discuss the risk factors for clients in the development of pressure ulcers, including the effects of aging on the immune system. Describe how the nurse uses the Braden Score for client assessment, when...

The nurse is caring for an 88-year-old diabetic client who has been admitted from a long-term...

The nurse is caring for an 88-year-old diabetic client who has been admitted from a long-term care facility for treatment of an infected, stage 4 pressure ulcer. Identify the different stages of pressure ulcers, describing the assessment findings for each of the 4 stages. Discuss the risk factors for clients in the development of pressure ulcers, including the effects of aging on the immune system. Describe how the nurse uses the Braden Score for client assessment, when the Braden Score...

The nurse is caring for someone in the CCU who has been admitted for unstable angina?...

The nurse is caring for someone in the CCU who has been admitted for unstable angina? The person is receiving Nitroglycerin 50mg/250ml D5W @ 30mcg/min. How many ml/hr. will the person receive to receive 30mcg/min? What is a special consideration in the administration of IV Nitroglycerin the nurse must know ? What common side effect would the nurse expect to the person to experience while receiving this medication? This person is discharged with a Rx for Nitroglycerin SL. How should...

A nurse is caring for a client who has a traumatic brain injury. The client, who...

A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first? a. Blood glucose b. Urinary output c. Motor responses d. Blood pressure

The nurse is caring for a client who has been receiving supplemental oxygen for hypoxia secondary...

The nurse is caring for a client who has been receiving supplemental oxygen for hypoxia secondary to pneumonia. Which laboratory data suggests that the client's oxygen flow rate can be safely decreased? A. PaO2 108 mmHg B. pH 7.39 C. PaCO2 45 mmHg D. HCO3 24 mEq/liter

A nurse is caring for a client who has a drainage evacuator. Which of the following...

A nurse is caring for a client who has a drainage evacuator. Which of the following is an appropriate action by the nurse? A. Discontinue the drainage system when it becomes full. B. Ensure the drainage suction is set on high pressure. C. Measure drainage by emptying into a graduated cylinder. D. Check the volume of the drainage every 24 hours.

A nurse is caring for a client in crisis who has endured a physical assault. The...

A nurse is caring for a client in crisis who has endured a physical assault. The nurse would expect to see which behavior associate with the integration phase of crisis?

2. A nurse is caring for a client who has a traumatic injury to the right...

2. A nurse is caring for a client who has a traumatic injury to the right ankle. The client has an unstable fracture with only a temporary splint in place. The client is having increased pain that is unresolved with IV narcotics and has 4+ edema, pallor, and pulselessness of the right foot. What should the nurse suspect, and what interventions should be taken?

A nurse is caring for a client who has schizophrenia and is experiencing delusions. Which of...

A nurse is caring for a client who has schizophrenia and is experiencing delusions. Which of the following actions should the nurse take? Encourage the client to rest quietly in bed twice per day Direct long conversations about the delusions toward reality-based topics. Avoid assessing client’s delusions Allow the client unlimited time to discuss the delusions when they occur.

Subjects