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NR 305 Week 7 Assignment; Anthony James iHuman Virtual Patient Encounter Worksheet
- Course
- NR301 (NR305)
- Institution
- Chamberlain College Of Nursing
NR 305 Week 7 Assignment; Anthony James iHuman Virtual Patient Encounter Worksheet
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NR305 Week 7 Anthony James iHuman Virtual Patient Encounter WorksheetName:
1. Situation, Background, Assessment, Recommendations (SBAR) Documentation
S Situation Anthony James is a 72-year-old patient admitted to palliative care
because of uncontrolled pain at the end of life. The daughter,
Shelly is his primary caregiver. Anthony is not responsive to my
questions. His daughter who reports that the patient is Catholic
would like me to return in a few hours when the patient is more
comfortable. I notified the nurse and asked to be informed when
the patient and his primary caregiver were ready for me to return.
The patient has been visited by the case management and pastoral
care to monitor discomfort and notify the healthcare provider if
the pain is uncontrolled.
B Background Anthony James has been receiving hospice care for the last several
months after he was diagnosed with bladder cancer eight months
ago. His family decided to shift the focus of his care to preserve
his life quality after radiation failed to improve his prognosis. The
primary reason for the encounter with the patient is metastatic
bladder cancer. Anthony gradually stopped taking food and drinks
by mouth for the last week and increasingly became restless and
uncomfortable. His admission to the palliative care unit is to
© 2023. Chamberlain University LLC. All rights reserved.
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6.13.23
, manage his symptoms and discharge him to home if possible.
A Assessment The primary issue experienced by Anthony James is uncontrolled
pain and restlessness. Another issue of concern is stage IV bladder
cancer with metastasis to the pelvic lymph nodes. Critical findings
discovered during the patient’s assessment include hypertension,
heart failure, oxygen dependence for two years, and COPD. The
patient has been unable to take routine oral and inhalation
medication for 24 hours, prompting the home hospice provider to
change his oral morphine to a rectal route.
HEENT
Head: Denies headache.
Ears: Denies changes in hearing.
Eyes: Denies vision changes.
Nose: Denies nasal congestion and nosebleeds.
Throat: Denies sore throat.
Denies open areas, rashes, abrasions, and lesions on the skin.
Has no shortness of breath. Reports weak cough, oxygen at 2L via
nasal cannula.
Reports psychological restlessness and discomfort.
Reports anorexia
Reports decreased level of consciousness.
© 2023. Chamberlain University LLC. All rights reserved.
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6.13.23
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