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.

you are to report the case to the doctor using SBAR format

Answer 1

Situation

Good evening sir,This is a staff nurse Sofia from ward 1 . this is about Ms billings. She is complaining of nausea and had two episodes of vomiting and also has blurring of vision. Her vitals are blood pressure 180/100 mm hg ,pulse rate 100/min, respiratory rate 20 per minute, temperature is 98.4f, MEWS Score 3, GCS 15

BACKGROUND

She was admitted for evaluation of recurrent falls. She is a known case of congestive heart failure ,coronary heart disease, rheumatoid arthritis and transient ischemic attack. She also has a history of cardiac stent placement, let hip replacement and umbilical hernia repair. She is allergic to Codeine. She is on multiple medications including methotrexate, Tylenol,digoxin,ASA and Lisinopril

ASSESSMENT

I think it is an episode of hypertension due to missing of the due pills. I have advised the patient to take the due antihypertensive medication and take rest. Presently the patient is stable.

RECOMMENDATION

Sir could you please come and see the patient. Kindly advise me of what is to be done in the the meantime.