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NR 305 Week 4 Assignment; Ben Bundy iHuman Virtual Patient Encounter Worksheet CA$30.43
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NR 305 Week 4 Assignment; Ben Bundy iHuman Virtual Patient Encounter Worksheet
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  • Course
  • NR301
  • Institution
  • Chamberlain College Of Nursing

1. Situation, Background, Assessment, Recommendations (SBAR) Documentation Write a fo-cused SBAR note summarizing Ben Bundy’s assessment for end-of-shift documentation. Include appropriate information in each section. Include all key findings in each section. Data should be well-organized and con...

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  • January 15, 2025
  • 8
  • 2024/2025
  • Other
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  • nr 305 week 4
  • nr 305 week 4 assignment
  • nr 305 week 4 assignment ben bundy

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  • Chamberlain College Of Nursing
  • NR301
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NR305 Week 4 Ben Bundy iHuman Virtual
Patient Encounter Worksheet

Name: Rebekah Walker


1. Situation, Background, Assessment, Recommendations (SBAR) Documentation
Write a focused SBAR note summarizing Ben Bundy’s assessment for end-of-
shift documentation. Include appropriate information in each section. Include
all key findings in each section. Data should be well-organized and concise.
Documentation should be professional with correct spelling.

Hint: This is a focused assessment SBAR; your summary should include a brief
review of pertinent findings. Type the appropriate information in each section
below to develop your focused SBAR note for end-of-shift documentation.

S Situation Ben Bundy is a 75-year-old male who presented to the ED
with increased SOB at rest, fever, and productive cough
Concise for about a week. He received breathing treatment via
statement of the nebulizer for 30 minutes and was placed on 3L NC. He is
purpose of the being admitted for Acute COPD exacerbation.
communication

B Background Mr. Bundy denies any depression, alcohol, or substance
abuse. He has a 40-year smoking history. He states that
Brief information he ran out of his medications, specifically his inhalers a
related to the week ago. Per his wife, he has not been able to speak in
clinical complete sentences since yesterday. No changes in
background of mentation. Mr. Bundy states that he cannot afford
the situation
medications.
A Assessment Mr. Bundy is AOx4, sitting in a tripod position leaning on
the bedside table. NKDA. Code Status: DNI. VS: T: 101°F;
Brief analysis and R: 24bpm; P: 88bpm; BP: 128/84 mmHg; SpO2: 86% on 3L
consideration of NC. Weight 150 lb.; BMI 20.4. 72” tall. Pain 2/10 on the
options pain scale in the chest from coughing; aching. Inspiratory
and expiratory wheezes were noted bilaterally anterior
and posteriorly. Productive sputum visualized on tissue
green in color. S1S2 heard on auscultation.
Barrel Chest visualized and use of accessory muscles
noted. Cyanosis to lip noted. Skin warm, flushed, and
diaphoretic.
Workup done before admission in ED:
Chest X-ray indicated hyperinflation with flat
diaphragm; RLL PNA due to focal consolidation.
ECG indicated ST 105.
Lab results: WBC 14,000 indicates Leukocytosis.
© 2023. Chamberlain University LLC. All rights reserved.
1

, 6.13.23

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