Question

SBAR. COPD-4 125% Zoom Add Page Table Chart Text Shape Media Comment SBAR: COPD S: Exacerbation of symptoms. Increased sputum production (thick with yellow color). Increased SOB upon exertion with O2 at 3LPM via NC continuous. Increased fatigue. Chest tightness. Decreased appetite. Edema noted in BLE. B: 67 y/o presented to the ER with the above symptoms, admitted to the Med-Surg floor. PMH of COPD, HTN, and GERD. Married. Retired. Enjoy being out in his garden daily 2 grown children, 4 grandchildren. Currently receiving: D5 at 50 ml/hr, Duonebs every 6 hours pm, Protonix (Pantoprazole) 40 mg, Singulair 10 mg at bedtime, Mucinex 600 mg, every 6 hours and Norvasc (Amlodipine) 10 mg. QD. 11 A: What are your assessment findings? R: Write down what MD orders for patient.

An assessment based on the situation for example for the falls you would assess the laceration, size swelling and amount of bleeding , around area, assess the ankle for pain scale, swelling, mobility. Do a complete skin assessment. Assess what they were doing before fall, going to the bathroom, reaching for personal item.

Answer 1

SBAR: COPD

Assessment findings: A 67 year old patient presented in the ER and admitted in Medical / Surgical floor with these symptoms. Exacerbation of findings of Increased sputum production (thick with yellow color), Increased shortness of breath upon exertion with oxygen at 3 LPM via nasal cannula continuous. Symptoms also noted with increased fatigue, chest tightness, decreased appetite and edema in the bilateral lower extremities.The patient has past medical history of COPD, Hypertensiion and gastroesophageal reflux disease.

Recommendations: The exacerbations of findings in the case of copd patients can be severe and life threatening. Treatments includes Oxygen therapy, Glucocorticoids which reduce inflammations, bronchodilators which can help expand the airways that will reduce the shortness of breath, respiratory stimulants, respiratory or ventillatory support if patient shortness of breath will increases, antibiotics and antivirals which will help to fight any bacterial lung infections and viral flu like infectons , etc

SBAR: Fall

Assesment findings: A 75 year old patient was admitted to Medical/Surgical floor 3 days ago with nausea and vomiting symptoms.Patient found lying on the floor in room, close to the bath room door. Patient has a laceration above the Right eye. Patient has left ankle pain. Vital signs: BP-148/92 mm Hg, Pulse- 96 beats per minute, Breathing - 20 breaths per minute, Temperature- 98.2 F, O2 saturation- 94% on RA. Patient is disoriented and confused and stated "where am I".

Past medical history includes Hypertension, hyperlipidemia, and osteoporosis. The assesment before fall will be that, when going to bathroom the patient may be got syncope which leads to loss of unconsiousness and fell down.

Recomendations:

1. Do a CT scan of the head to check any intracranial bleeding or any infarcts in the brain and also evaluate any bony injury in the skull especially in the Right orbital area.

2. Check the Blood pressure level in specific intervals, check the lipid profiles ( c/o hyperlipidemia ), and check the skelton regions (entire lower extremities and upper extremities, especially in the left ankle area)

3. Check the Sugar level in the blood and also check the routine blood tests also.