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NURS 201 Focused Exam Infection SBAR Shadow Health

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NURS 201 Focused Exam Infection SBAR Shadow Health ED Nursing Note SBAR Reflections Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a cl... inician and gives your instructor insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your documentation as you respond to the prompts at the bottom of the page. Documentation Review SBAR Student Response Model Documentation 1. Situation Ms. Patricia Young is a 74-year-old White woman admitted today from the ED with a diagnosis of UTI and new onset confusion. 2. Background Ms. Young has a history of frequent UTIs, bladder leakage, hypercholesterolemia, and a cholecystectomy at age 48. Yesterday she showed signs of confusion at home and today became increasingly confused, somnolent, and incontinent of urine, complaining of burning with urination and generalized abdominal discomfort. Her treatment plan is to treat her for UTI and monitor her mental status. She has had labs, a urinalysis, and urine culture and sensitivity.Student Response Model Documentation 3. Assessment Ms. Young's vital signs are stable. She had a fever of 38.3C when she arrived but that is now down to 38.1C. She complained of pain with urination so she was medicated with Ibuprofen 600 mg P.O. and along with starting Bactrim 1 tablet every 12 hours, she was medicated with Pyridium at 5 PM. She is on bedrest with BRP and we have her on a schedule of offering toileting every 2 hours on the odd hours. Her last void was 5 PM and she did still have some discomfort with urination so she can have another dose of Pyridium tonight before bedtime. Her urine was pink amber and she is continuing to wear an incontinence pad. She is oriented to person and time but not place. She is following some verbal instructions. She is ordered neuro checks every 2 hours. She moves all extremities. Along with being overweight with a BMI of 28, her gait is unstable so she is not getting up without assistance. Her heart sounds are regular and breath sounds are clear in all fields. She denies SOB. She has an IV in the left antecubital infusing D5.45NS at 83 mL/hr. She is receiving the first of 2 liters that she is ordered. Prior to coming to the ED she had not been eating or drinking. She is taking P.O. fluids now and had 180 mL urine in the last hour. PT is consulted for the morning to assist with her gait and exercise and the nutritionist has been consulted for tomorrow regarding meal planning and weight management.Student Response Model Documentation 4. Recommenda tion Based on my assessment, I would recommend the following: She can have Pyridium 3 times a day for 2 days. Since her first dose was 5 PM, she can have another dose before bedtime. The femtrace ordered for her is to be started in the AM. It is on the Beers list and isn't appropriate for her so you will need to get that order changed by morning. "To help you have bladder control, a medication was ordered called Femtrace. This is not the best medication for you to take because of your age. A call will be made to your physician to get this changed to something that will be more helpful in addressing bladder control for you." Order a meal for her so she can eat once they get up to your unit. Continue to monitor her mental status and monitor for fever. There was some confusion with her medications that was discovered during her medication reconciliation. She is taking 2 statins at home: Lipitor 20 mg that she takes with breakfast and Pravachol 10 mg that she takes at bedtime. She reports that she thinks Lipitor was a newer prescription, so we think that there might have been a misunderstanding about discontinuing the Pravachol once the Lipitor was begun. For now she is ordered the Lipitor prescription and tomorrow it will need to be followed up with her primary care physician. She needs to stay on the toileting regimen every 2 hours on the odd hours. To keep her on schedule we started the neuro checks on the odd hours as well [Show More]

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