NR 305 Week 8 Discussion Topic
Please choose one of the patient scenarios below. Next, complete a rapid assessment, and provide a SBAR report to a classmate. Remember to include all concepts of patient safety, standard precautions, and professional standards.
You are covering for a coworker w...
nr 305 week 8 discussion topic please choose one of the patient scenarios below next
complete a rapid assessment
and provide a sbar report to a classmate remember to include all concepts of patie
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Rapid Assessment of a Client (graded)
Please choose one of the patient scenarios below. Next, complete a rapid assessment, and provide a SBAR
report to a classmate. Remember to include all concepts of patient safety, standard precautions, and professional
standards.
1. You are covering for a coworker who is off the floor for lunch, when you suddenly hear a loud crash
coming from a nearby patient room. You quickly run in and discover Mr. Johnson who was admitted
yesterday with a diagnosis of cerebral vascular accident (CVA) unconscious on the floor between the
bed and the bathroom.
2. You are called to the room of 2-year-old Jonah by his mother who states the child has suddenly started
breathing very loudly and does not look right. Upon entering the room you quickly recognize that the
child is in respiratory distress as his lips are cyanotic and the use of accessory muscles is evident.
3. You are in the process of admitting Ashley, a 27 year old who is 28 weeks pregnant with her first child,
to the obstetric unit for complaints of headache, dizziness, and swelling of her lower extremities when
she suddenly begins seizing.
Professor Agen and class,
1. You are covering for a coworker who is off the floor for lunch, when you suddenly hear a loud crash coming from
a nearby patient room. You quickly run in and discover Mr. Johnson who was admitted yesterday with a diagnosis
of cerebral vascular accident (CVA) unconscious on the floor between the bed and the bathroom.
As I enter the room I observe Mr. Johnson unconscious on the floor. I instruct the CNA, that followed me into the room,
to call for a rapid response. A rapid response will bring the hospitalist on the unit, ED doctor, radiology, lab, respiratory,
and other trained personnel. Certain people are responsible for bringing the crash cart. While waiting for a response, I
will make sure that there is no tubing wrapped around Mr. Johnson (maintaining his oxygen) and have the CNA to move
anything that is in the way. As doing this, I will be talking to the patient while assessing his status. I would call to the
patient by name and explain things as I do them. I would have the CNA start getting vital signs while I check for any
injuries from his fall. Mr. Johnson starts to come around and I ask him to tell me his name, where he is, and what
happened. I tell him to try to lay still until we get more help and offer him a blanket. I ask him if he is having any pain. I
check his pupil reaction with my pen light and ask him to smile to check facial symmetry. I check his peripheral pulses
while looking for any skin discoloration. I am also watching his breathing pattern. At this time everyone arrives and the
doctors start assessing Mr. Johnson.
Situation – I heard a loud noise come from Mr. Johnson’s room at approximately 1130. We entered the room to find him
on the floor unconscious between the bathroom and bed. I instructed the CNA to call a rapid response as we entered the
room.
Background – Mr. Johnson was admitted yesterday with a diagnosis of CVA (cerebral vascular accident). Alert and
oriented x3, VS stable, no known allergies, normal saline @ 125mL/hr, left sided weakness, slight left sided facial
drooping, peripheral pulses equal and strong, reports no pain using a number scale.
Assessment – Mr. Johnson is easily aroused, easily oriented. BP 162/58, P 78, R 20, T 97.7, O2 97% on 2 liters NC. Reports
pain of 3 in right wrist. Peripheral pulses equal and strong. Patient states “I had to go to the bathroom and didn’t want to
bother anyone”.
Recommendation – CT of the head to make sure there are no new injuries, lab will draw CBC, CMP, and PT/INR. X-ray of
right wrist. Patient is not disoriented, need to reinforce using the call light for help getting up. Place urinal at bedside.
Irene
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