NUR 643E WeeK 2 Assignment SBAR Assignment


SituationHello. I am _____, a student nurse from ______, reporting from the Emergency Department’s Medical Unit. I’m here for my 54-year-old patient N.S., who was hospitalized today, January 4, 2023. The patient arrived at the Emergency Department two hours ago complaining of difficulties breathing, coughing, and congestion for three days. According to the patient, simply going to the restroom causes him to lose his breath. He reports coughing and hacking up yellow mucus, and needing to sit down to regain his breath after a short walk.
BackgroundThe patient reports having difficulties breathing, coughing, and congestion for the previous three days. He also claims to be out of breath just going to the restroom. He says he starts coughing and hacking up yellow stuff, and had to sit down to collect his breath after a short walk. He also reports a history of hypertension, DM, high cholesterol, and smoking tobacco for the past 10 years. He claims he was examined at his primary care physician’s office six months ago for identical symptoms. He was diagnosed with acute bronchitis at the time and was treated with beta-blockers, presumptive antibiotics, and a small dose of oral steroid taper. This treatment did not relieve his symptoms, and he rapidly deteriorated over six months. He claims to have lost 15 pounds during the last year.
AssessmentThe patient presents with symptoms of a respiratory infection. His cough has been getting worse over the past 30 minutes, with yellowish sputum and worsened shortness of breath. The vital signs are as follows: BP 153/91, apical HR 111/minute and regular, RR 26/minute and slightly laborious, and temperature 101.7F. A sizable, non-tender firm lymph node inside the right supraclavicular fossa is discovered during a neck examination. Except for the right mid-anterior and mid-lateral lung regions, both lungs are resonant by percussion. Auscultation indicates bilateral vesicular breath sounds that are decreased. In the right mid-anterior and right mid-lateral lung areas, bronchial breath sounds, late inspiratory crackles, and rhonchi can be detected. The remaining lung fields are clear. Heart percussion and auscultation indicate no substantial abnormalities. Clubbing is seen on the fingertips. The ER doctor conducted an EKG, which revealed no abnormal cardiac rhythms or signs of myocardial infarction (Cillóniz et al., 2019). The patient is suspected of having pneumonia based on the above findings.
RecommendationAdditional diagnostic tests should be ordered to support the suspected diagnosis of pneumonia, including a complete blood count, serology report of C reactive protein, and chest X-ray (Triana et al., 2020). The culture of the patient’s sputum should also be taken to identify the causative microorganism. When pneumonia is confirmed, the patient can be started on antibiotic therapy, as prescribed by the reporting physician. The treatment may comprise Cefotaxime 250 mg intravenous B.D., Ampicillin 125 mg iv after 6 hours, Nebulization with salbutamol, Oxygen now SOS, and 10 drops Panadol based on the American Thoracic Society and Infectious Diseases Society of America clinical practice guidelines for the treatment of adults with pneumonia (Metlay et al., 2019). The patient will be educated on the importance of complying with antibiotic therapy for a positive outcome. The patient will also be informed about the benefits and side effects of each medication prescribed based on the precise findings from previous studies (Olson & Davis, 2020).
ReferencesCillóniz, C., Dominedò, C., & Torres, A. (2019). An overview of guidelines for the management of hospital-acquired and ventilator-associated pneumonia caused by multidrug-resistant Gram-negative bacteria. Current Opinion in Infectious Diseases32(6), 656–662. Metlay, J. P., Waterer, G. W., Long, A. C., Anzueto, A., Brozek, J., Crothers, K., Cooley, L. A., Dean, N. C., Fine, M. J., Flanders, S. A., Griffin, M. R., Metersky, M. L., Musher, D. M., Restrepo, M. I., & Whitney, C. G. (2019). Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. American Journal of Respiratory and Critical Care Medicine200(7), e45–e67. Olson, G., & Davis, A. M. (2020). Diagnosis and Treatment of Adults With Community-Acquired Pneumonia. JAMA. Triana, A. J., Molinares, J. L., Del Rio‐Pertuz, G., Meza, J. L., Ariza‐Bolívar, O., Robledo‐Solano, A., & Acosta‐Reyes, J. (2020). Clinical practice guidelines for the management of community‐acquired pneumonia: A critical appraisal using the AGREE II instrument. International Journal of Clinical Practice74(5).

NUR 643E WK2 SBAR Discussion

Clinical Log in the SBAR Format

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SituationA middle aged man was brought in the emergency department with a chief complaint of difficulty in breathing, stabbing chest pain radiating to the back, tightness of the chest, and nausea. There were several advanced practice registered nurses (APRNs), one of whom was my preceptor. She guided me through clerking the patient and was there to assist me since this was a medical emergency. All the other APRNs and staff nurses who were without a patient were also there to assist. The patient was a 45 year-old Caucasian male and was brought to the ED by his wife. He looked anxious and confused.NUR 643E WK2 SBAR Discussion
BackgroundThe patient has a history of smoking and alcohol consumption for the last 20 years and still smokes and drinks. He has been admitted four times before for pneumonia and severe hypertension. He does not have a surgical history. He lives with his wife and has a son who is in high school. He was sweating and had obvious signs of labored breathing. He is a chef by profession and also has a history of obesity and hypertension. His vital signs on admission were P=100 b/m, RR=22/m, BP=100/50 mmHg, and T=36.1°C (96.98°F). His BMI was 30.5 kg/m2.
AssessmentThe patient was well-groomed and dressed appropriately for the weather and time of the day. He was oriented in place, space, time, and person; and his pupils were both equal, round, and reactive to light and accommodation (PERRLA).After assessing the patient’s symptoms by way of objective assessment and taking note of the history given during the subjective assessment, the unanimous impression was that Mr. C.F. was suffering from acute coronary syndrome. To be specific, he had acute myocardial infarction (AMI). Patient C.F. significantly had notable cardiovascular risk factors in the form of obesity, smoking, alcohol consumption, and hypertension (Barstow et al., 2017).He required urgent administration of streptokinase, acetyl salicylic acid, opioid pain relief, a tranquilizer, and oxygen by face mask at 2-4 L/min (Carville et al., 2015).
RecommendationThe patient needed immediate admission in the intensive care unit for treatment and observation. He would also need referral for evaluation by a cardiologist.For a confirmation of the diagnosis, patient C.F. would need to undergo an ECG as well as laboratory blood tests for CK-MB and troponins (Barstow et al., 2017). These would indicate the characteristics STEMI abnormalities on the ECG and possible myocardial injury or necrosis through the CK-MB and troponin levels. NUR 643E WK2 SBAR DiscussionOnce stabilized, the patient would have to be taken through an evidence-based nurse-led educational intervention for lifestyle change and healthy living (Snaterse et al., 2016; Kirchberger et al., 2015). He would be taken through the behavioral steps necessary for achievement of smoking cessation. This will be done both as an inpatient and later on during follow up. The patient would also be guided through measured aerobic exercises that he would be able to perform even at home. These are isotonic exercises that would assist in controlling the hypertension and reducing his big weight. He would also be taken through the appropriate diet for him in terms of diet management and the importance of taking food rich in fruits and vegetables. Lastly but not least, he would be educated on the vital importance of complying with the medications that he would be discharged with. This is because these would be instrumental in the secondary of a subsequent myocardial infarction which may be fatal.
ReferencesBarstow, C., Rice, M., & McDivitt, J.D. (2017). Acute coronary syndrome: Diagnostic evaluation. American Family Physician, 95(3), 170-177., S.F., Henderson, R., & Gray, H. (2015). The acute management of ST-segment-elevation myocardial infarction. Clinical Medicine, 15(4), 362-367., I., Hunger, M., Stollenwerk, B., Seidl, H., Burkhardt, K., Kuch, B., Meisinger, C., & Holle, R. (2015). Effects of a 3-year nurse-based case management in aged patients with acute myocardial infarction on rehospitalization, mortality, risk factors, physical functioning and mental health. A secondary analysis of the randomized controlled KORINNA study. PLoS ONE 10(3), 1-17., M., Dobber, J., Jepma, P., Peters, R.J.P., Ter Riet, G., Boekholdt, S.M., Buurman, B.M., Op Reimer, W.J.M.S. (2016). Effective components of nurse-coordinated care to prevent recurrent coronary events: A systematic review and meta-analysis. Heart, 102(1), 50-56.

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