Question

You are taking care of Mr. A. Burmond. You complete a chart review, take note of current orders and enter the patient's room to introduce yourself and complete a full assessment. You note that Mr. Burmond is awake, but lethargic when you enter his room. He knew the time, but not the day of the week. His speech is clear and easy to understand. Pupillary response was reactive to light. His wristband is in place and he responds correctly to his name and date of birth. Both side rails are up, and his bed is at the lowest position. You note shortness of breath, especially with readjustment in the bed. Crackles are auscultated in the lower lobes but note no evidence of stridor or wheezing. Respirations are 19 per minute. Saturation is 92% on 2L oxygen therapy. Temperature is 99.9 F. His heart sounds are present, with no abnormal beats upon auscultation. His BP is 142/89 and heart rate is 92. Pulses are all present, 2+ in upper extremities and 1+ in the pedal region. Capillary refill is less than 2 seconds. No edema noted in lower extremities. Bowels sounds present in all quadrants. No pain disclosed. Active ROM and muscle strength is 1+ in all extremities. No skin breakdown noted. Needs minor assistance but has bathroom privileges. IV line in right forearm flushed with no issues. IV fluid therapy infusing.

Document an SBAR Note of your findings

Answer 1

Situation :

Mr. A.Burmond is awake but lethargic. He knew time but unaware of day of the week. He has shortness of breath.

Background :

Mr. A Burmond is lethargic , unaware of day if the week . He has shortness of breath and crackles on auscultation . Pulse rate is 19 beats per min and BP is 142/89 mm Hg . He has raised temperature upto 99.9°F . His heart rate is 92 beats. No edema present .

Assessment :

My assessment of the situation is patient may be having cardiac event or pulmonary event ( respiratory distress syndrome ) as crackles are heard on auscultation with raised BP and heart rate and shortness of breath.

Recommendation :

IV fluid infusion

Oxygen therapy