Question

• You are performing bedside shift report to the night nurse. The patient is a 70-year-old male with a COPD exacerbation in room 107, named Sam Fire. When he arrived, he was very short of breath and had an SPO2 of 83%. In the ER he was given steroids, nebulizer treatments, and was put on 2L of oxygen on a nasal cannula (which he is still on). In addition to COPD, his history is hypertension and he is a current smoker (he has been smoking since he was 19 years old). He is a FULL CODE. He has allergies to Amoxicillin and Percocet. During your shift, the client had a chest x-ray, which the doctor reviewed with him, that showed pneumonia in the left lower lobe. He was started on an antibiotic that was due at 1400 but you didn’t get it started until 1500 and it is supposed to go every 6 hours. The night nurse has the dose due at 2000. The client is a fall risk who gets up frequently with an unsteady gait. He often gets up without assistance, setting off the bed alarm. When he ambulates, he also exhibits shortness of breath and his SPO2 is 87% (normal for him is 91%). When he does use assistance, he requires a walker and a gait belt. His wife, kate, is his primary caregiver. She would like an update if anything happens or changes. Her number is 730-555-5555.
• Your 0800 assessment (and reassessment at 1200 and 1600).
  • Neuro: Alert and oriented x4
  • Cardiac: Regular rate and rhythm
  • Respiratory: Productive cough, diminished breath sounds in bilateral lower lobes
  • GI: Positive bowel sounds, nontender
  • GU: Deferred, patient urinating independently clear, yellow urine
  • Vitals at 1600: Temp 98.1 F, BP 135/81, HR 88, RR 26, SPO2 91%

• Create an SBAR
  • S (Situation):
  • B (Background):
  • A (Assessment):
  • R (Recommendation):

Answer 1

Situation	I am concerned about fall due to his unsteady gait and breathing difficulty when he ambulates mostly turning off the call bell. Now 2L O2 via nasal cannula He requires a walker and gait belt for assistive walking.Due to investigations and client behaviour the antibiotic was not on time and delayed and the subsequent dose has to be adjusted accordingly
Background	Mr.Sam Fire is 79year/M admitted with complaints of exacerbation of COPD,severe shortness of breath is a known case of hypertension and active smoker. Allergic to Amoxicillin, Percocet and on FULL CODE,
Assessment	T:98.1F P:88 ,regular BP:135/81 RR:26,productive cough with diminished breath sounds with bilateral lower lungs SPO2:91% He is alert ,oriented with positive bowel sounds His chest x Ray reveals pneumonia in left lower lobe The colour of the urine is yellow
Recommendation	I would suggest the following Prevent fall Administer the antibiotics Maintain oxygen saturation at 91% with 2L O2 via nasal cannula Observe patiwnt for any exacerbation