Question

Sarah Getts, 77 yr-old, Dx- Chronic Renal Failure, admitted with hyperkalemia (5.9, Eq/L)/hyponatremia (128mEq/L). No known allergies (NKA). Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Disoriented to time and place, speech slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. 50% intake. High fall risk. Renal diet. Family in room with patient very concerned.

Write an SBAR.

Answer 1

SBAR

The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition.

Situation

Sarah getts, 77year old admitted with hyperkalemia and hyponatremia, diagnosed as chronic renal failure

Background

Patient was diagnosed as chronic renal failure, no known past history, no known allergy. With the vitalsigns of Vital signs -Temp 98.8, BP 102/76, P 102- irregular, RR 22, SaO2 90%, cardiovascular on telemetry with Sinus irregular rhythm. Disoriented to time and place, speech slurred. Pupils PERRLA, eyes clear. 20 ga. Hep-Lock in right forearm, skin warm and dry, generalized weakness with recent weight loss. 50% intake. Renal diet

Assessment

Patient has chronic renal failure with hyperkslemia, high fall risk for the patient. I think the hyperkalemia should be corrected inorder to prevent futher cardiac problem. Family in room with severe concerned. Patient may develop cardiac arrhythmias if hyperkalemia treatment failed. Hypo natremia should be correct inorder to reduce neurological symptoms

Requestor Recommendation

I think hyperkalemia and hyponatremia should be correct inorder to prevent further complications. Pottassium level:5.9meq/l, sodium, :129meq/l

Perodic monitoring of k+and sodium is important. Strict renal diet should be follow.