N101 Seminar: Documenting and Reporting – Case

N101 Seminar: Documenting and Reporting – Case Study Part 1: The nurse calls the physician The nurse is caring for Mr. Jones, a patient in Room 462. The shift began at 0700 hours, and the time is now 1405 hours. James Jones, a 67-year-old male, was admitted three days ago with a diagnosis of right lower lobe pneumonia. He has a medical history of hypertension, controlled with metoprolol, a beta-blocker. He smoked cigarettes, one pack per day, prior to admission. He has no surgical history. He is allergic to aspirin (states it makes him itch). He is able to ambulate to the bathroom independently. He receives an antibiotic, ceftriaxone 1 gram IV, every 24 hours, and is due for his next dose at 1700 hrs. He had been febrile and improving for the past 24 hours. However, this afternoon at 1400 hours, his temperature is 102.4 F. pulse 100 bpm and regular, respiratory rate is 22 with labored, pulse oximetry is 92% on room air, and blood pressure is 110/68 mm/Hg. His usual blood pressure is around 125/80 mm/Hg. Mr. Jones has a productive cough with light yellow sputum. Crackles may be heard at the base of his right lung. He complains of chest pain with coughing, but none at rest. He states that he becomes short of breath with exertion. His peripheral pulses are slightly diminished on all four extremities, with no edema noted. He is complaining of nausea but has not vomited. He drank 150 ml of fluid since the beginning of your shift. His abdomen is soft and non-tender. His last BM was prior to admission. He has voided 180 ml since 0700. The nurse is concerned about Mr. Jones vital signs and intake and output. The nurse asks the physician to please come and evaluate the patient. Give example of an SBARQ report to call the physician; use the tool provided. Part 2: The physician evaluates the patient and writes orders. Use the following information to formulate an end-of-shirt report to the nurse on the next shift at 3:00pm The physician evaluates the patient and orders: a chest xray, a sputum culture, blood cultures, a CBC (complete blood count), an anti-emetic, prochlorperazine 10 mg tablet orally every 8 hours prn; acetaminophen 650 mg every 6 hours prn for fever; continue the ceftriaxone IV as ordered; Normal Saline IV at 150ml/hour, and begin incentive spirometry every 2 hours. The physician writes additional orders to encourage oral fluid intake, to continue to monitor intake and output and to call for output less than 500 ml in 8 hours. The nurse medicates the patient with prochlorperazine and acetaminophen at 1430 hours, starts an IV of 1000 ml Normal saline to run at 150 ml/ hour in Mr. Jones’ left forearm, contacts the respiratory therapist to begin incentive spirometry, draws the blood and sends it and a sputum specimen to the lab, and orders the chest xray to be done as soon as possible. The nurse has checked back with Mr. Jones at 1500 hours, and his temperature is now 100.6 F and his nausea is relieved. Since he was medicated, he drank 100 ml of ginger ale. He has not yet voided. There are no other changes to his assessment. Give an example of SBARQ tool to give report to an RN receiving this patient.

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