DrElephant1616
CASE SCENARIO Mrs. J. 88 years old, was admitted this evening from…
CASE SCENARIO
Mrs. J. 88 years old, was admitted this evening from long term facility. The family says the patient was lethargic and confused during their visit. Her admitting vital signs were T 101F, P92 and irregular, R 28 and short and shallow, BP 110/70, pulse ox 94%. Her physician was called for admitting orders and was informed of the UA report from the long-term facility. He will come in tomorrow morning to see her. She was given acetaminophen at 8:30pm and her current temperature is still slightly confused. She has an IV infusing. She is in a private room.
Client Background
Now that you have listened to the handoff report, take a moment to review important client
background. Have a look at the patient care Kardex and nursing progress notes.
Patient Care Kardex
VS q4h
Diet: DAT
LBM: On admission
IV: 0.9% NS at 75 mL/hr
#24 angiocath Right Forearm
Lab: CBC, chem panel, Urinalysis
PRN Medication:
Acetaminophen 325 mg tabs ii q4h prn temp greater than 101 degrees F
Nursing Progress Notes
Documentation of latest nursing progress notes:
1600 Turned, incontinent of urine, strong urine odor, incontinent pad applied. A. Cann RPN
1700 Family in to visit. Upset, called physician. A. Cann RPN
1830 Transferred to hospital per order. Recent UA (urine analysis) culture reports
show + MRSA. Unable to contact physician to inform. Copy of report included with transfer.
T. Gage RN
Initial Assessment
It is important to be able to identify pertinent patient information such as subjective and objective data and normal and abnormal findings. Now that you have obtained some initial data about your patient from the handoff report, the nursing care kardex, and the patient’s medical history take a few moments to write down your data and findings you have identified.
Follow-Up Nursing Action Plan
Mrs. J slept 1 to 2 hours at a time during the night and remains confused. She has developed a productive cough and is expectorating a small amount of thick, creamy, yellow-colored phlegm. Her morning vital signs are T 100.8° F, P 110, R 32, BP 114/82, pulse ox 92%. At 6:30 AM the physician visits and leaves the following orders:
Vancomycin 500 mg q8h IVPB
Insert indwelling urinary catheter
Bed rest
Chest x-ray/ECG
Oxygen 2 L/min/NP, pulse oximeter q4h
I & O, fluid intake
At times the right action for the nurse is to communicate their concerns about a patient’s clinical status. It is important to be confident and skilled in communicating with members of the health care team so they can signal the need for immediate action and support when required. “Good clinical communication is important in clinical reasoning and decision-making”. ISBAR is an effective way of communicating during phone calls and increasing patient safety (Mikos, 2007).
Using ISBAR, write how you will communicate with the patient’s physician over the phone when you call for admitting orders
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