Question

Mr. Charles Lamont is a 64-year-old patient who is visiting his primary care physician with complaints of vomiting x 3 days and inability to keep anything down. His wife is waiting for him in the lobby. She is hoping that Mr. Lamont will tell the physician about his recent bout of coughing and shortness of breath. He smokes 1½ packs of cigarettes per day. His wife has been encouraging him to stop, but he has not shown any interest in quitting. Laura, the registered nurse, takes Mr. Lamont into an examination room. Laura asks him about his overall health and he tells her about a nagging cough and feeling of dizziness when he tries to get up. Laura examined Mr. Lamont and observed dry, scaly skin, an inflamed hemorrhoid, and tremors to his fingers and toes. The patient also vomits after drinking a cup of apple juice. He also reports pain in his feet. Laura instructed the UAP to takes Mr. Lamont’s vital signs with the following results: blood pressure, 156/94 mm Hg sitting; temperature, 98.8° F orally; radial pulse, 52 beats/min and irregular; respirations, 25 breaths/min and regular; and pulse oximetry 87%. Laura retakes the pulse prior to documenting and reporting the findings to the physician. She also documents the vital signs in the computerized medical record.

Mr. Lamont tells his wife that the physician told him his respiratory rate was increased. Many factors can contribute to increase respiratory rate. Mrs. Lamont asks Laura what could cause him to breathe faster?

a. Write at least 4 factors that could cause increase respirations?

1. Given Mr. Lamont’s history, what site should the UAP use to monitor the temperature? Give your rationale.

2. Laura used SBAR communication technique to report the patient’s findings to the physician.

a. What does SBAR stands for? Why did Laura use SBAR?

3. Which of the QSEN competencies were used in caring for Mr. Lamont?

a. Define the QSEN(s) that you choose

  

Answer 1

Ans) 1. The best site for the UAP to monitor Mr. Lamont's temperature would be by ear (tymphanic).

- Mr Lamont is a smoker so depending on when he had his last cigarette, if it was recent, an oral temperature may yield inaccurate results.

- A tymphanic temperature is the next best choice.

2) a. SBAR stands for:

S: Situation

B: Background

A: Assessment

R: Recommendation

Laura used SBAR as a communication tools with the physician to report a Situation that requires the immediate action and its structure to address a important facts clearly.

3) a. Teamwork and Collaboration- by using the SBAR to communicate with the doctor demonstrates collaboration with other healthcare team members and teamwork to form the best care plan for Mr lamont.

- Evidence based practice - by using the Vitals Signs of Mr lamont and monitoring them accurately, we used these evidence to support the nursing diagnosis and interventions.

- Safety - when assessing Mr lamont's blood pressure during his postural changes (lying, sitting and standing). It's important to provide safety for him and keeping him free of injury and/or falls.