Include the following sections (detailed criteria listed below and in the grading rubric). Answer the questions under each section with explanation and detail.
1. Situation, Background, Assessment, Recommendations (SBAR) Documentation
Write a focused SBAR note summarizing Anthony James’ assess...
NR305 Week 7 Anthony James iHuman Virtual
Patient Encounter Worksheet
Name: Kathia Martinez
1. Situation, Background, Assessment, Recommendations (SBAR) Documentation
Write a focused SBAR note summarizing Anthony James’ assessment for the
end of shift report. 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.
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 Anthony James 72y/o admitted to palliative care for
management of uncontrolled restlessness and
Concise statement discomfort due to stage IV bladder cancer. V/S to be
of the purpose of done PRN. DNR/Palliative care. Bedrest. Diet: ice chips
the communication and liquids if desired.
B Background The patient was diagnosed with bladder cancer 8
months ago. Radiation failed to improve prognosis. The
Brief information family decided to preserve his quality of life. Receives
related to the home hospice care.
clinical background Gradually stopped taking food and drinks by mouth.
of the situation Restlessness and discomfort have increased. POC is to
manage symptoms and then d/c him home.
A Assessment 22-gauge 1-inch non-coring port needle. O2 at 2L via
N/C, titrate PRN to maintain oxygenation saturations
Brief analysis and greater than 92%. Bisacodyl 1 rectal suppository q12h
consideration of PRN constipation. Diphenhydramine 25mg IV q6h PRN
options itching. Ondansetron 8mg IV q4h PRN nausea or
vomiting. Morphine PCA, restlessness, grimacing and
moaning, DNR, Tachycardia.
R Recommendation Sedative to keep patients comfortable. Proper
resources to family on palliative care. Case worker
Suggestion of what information to daughter for palliative care.
you believe the
client needs
Did you feel comfortable and knowledgeable in Anthony’s simulation? Yes, the
simulation provided clear guidelines for managing Anthony's symptoms and
highlighted the importance of palliative care principles.
What did you learn? I learned about the specific medications and interventions
used to manage symptoms in palliative care, the importance of family support,
and the role of comfort measures in end-of-life care.
What additional information is needed to better care for Anthony? More
detailed information on his pain levels, specific preferences for care, and any
prior responses to medications would be beneficial.
What specific questions would you like to ask his caregiver?
1. How is Anthony’s comfort level currently?
2. Are there any specific concerns or preferences from the family regarding his
care?
3. How has Anthony responded to the prescribed medications and interventions
so far?
3. Post-Case Questions (Provide at least one scholarly source from the Chamberlain
Library to answer the questions in this section. Provide an APA in-text citation
and full APA reference for the scholarly source).
Discuss the importance of balancing the psychological aspects of end-of-life
care, such as pain management and symptom control, with the psychosocial
and emotional needs of the client and family when developing and
implementing a plan of care for clients at the end of their life.
Balancing psychological aspects of end-of-life care involves addressing both
physical symptoms and emotional needs. Effective pain management and
symptom control are essential to improving the patient's quality of life. Equally
important is providing psychosocial support to both the patient and family,
ensuring their emotional, social, and spiritual needs are met. This holistic
approach fosters a compassionate environment that respects the dignity and
wishes of the patient while also supporting the family through a difficult time
(Mehta & Chan, 2018).
Discuss how you can ensure that established protocols, like pain management,
are effectively tailored to each client’s unique needs and preferences to
provide client- centered care.
To ensure protocols are tailored to each client, healthcare providers should
conduct comprehensive assessments that include the patient's medical
history, current symptoms, and personal preferences. Regularly updating
care plans based on the patient’s feedback and condition changes is crucial.
Engaging in open communication with the patient and family allows for
adjustments to be made promptly, ensuring that care remains aligned with
the patient’s unique needs and goals (Ferrell et al., 2019).
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller studyguider55. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $20.49. You're not tied to anything after your purchase.
