Question

Ms. Billings, a 65 year old Caucasian woman was admitted to your long term facility 1 week ago after repeated history of falls at an assisted living facility out of state. She was placed here in the Virginia facility in order to be close to her only daughter. She is currently complaining of nausea, stated that she'd vomited twice already during the night and that her eyes feel a little blurry, even with her glasses on.

PMH--Congestive Heart Failure, CAD, Rheumatoid Arthritis, Transient Ischemic Attack (TIA).
Surgical hx: Cardiac stent, left hip replacement, Umbilical hernia repair.
Allergy--codeine
Meds--Methotrexate, Tylenol 325mg QID PRN pain, Digoxin 0.125mg po daily, ASA 81mg every other day, Lisinopril 5 mg po daily.

Work to do:
1. Using SBAR, report the above case to the doctor. If there's information missing, add it in. You have to be creative in doing this assignment.

report the case to the doctor using SBAR format

Answer 1

REPORT SHEET

Situation:

Patient Name: Mrs. B

Date:

Admitting from: last week

Reason for admission: History of falls and complaints of blurring of eyes, nausea and vomiting

Background:

Past medical history:Transcient ischemic attack, congestive heart failure, CAD, rheumatoid arthritis

Past surgical history: cardiac stent, umbilical hernia repair, left hip replacement

Allergies: Codeine

Assessment:

Vitals:Temperature, pulse, respiratory rate, blood pressure, pain, oxygen saturation

Oxygen:

Nausea: yes

Vomiting: twice a day

Medications: Methotrexate, Tylenol, Digoxin, ASA, Lisinopril

IV Fluids

Antibiotics

Risk for falls: high risk due to blurring of eyes

Recommendations:

Plan of care: nutrition, rest,fluid and electrolyte, sleep, safety.