- Read the following scenario and write an SBAR report to include the information you will give to the oncoming nurse at 0730hrs. (10 marks)
SBAR FOR MR LOMBARDI
You are an RPN on the night shift on a Palliative Care unit. You are caring for Mr. Lombardi, an 89-year-old male who was admitted to the Palliative Care unit at 1630hrs from the emergency department. Mr. Lombardi was brought in to the Emergency department for shortness of breath and confusion. He has a history of lung cancer with metastasis to the brain. He is a DNR (Do not Resuscitate) and has no known allergies. Mr. Lombardi has been admitted for symptom management. He was given morphine IV at 1800hrs and is not complaining of pain and his breathing is normal. He has a coccyx dressing which is intact. He is receiving Normal Saline in his right forearm. Vital signs are BP 140/70, P-78, Temp. 36.5, Resp. 20 Oxygen saturation 98% on 2/Litres Nasal Prong. His daughter is at the bedside and requesting to see a doctor. The nurse called the Palliative Care Doctor (Dr. James) who will see Mr. Lombardi later today. The daughter states they are unable to cope at home and is requesting that her dad be transferred to a Palliative Care Unit closer to home.
SOAP NOTE AND NARRATIVE NOTE FOR MRS JONES
Please complete a SOAP Note and a Narrative Charting. You must include a date and time in your documentation using the 24-hour clock. Your designation to sign off the documentation is SCPNS(Seneca College Practical Nursing Student).
15 Marks (for SOAP Note)
15 Marks (Narrative Charting)
2. You are the nurse caring for Mrs. Jones and you started your shift at 0730 and your shift will end at 1530. You have completed an assessment on Mrs. Jones at 0800 and below are your findings.
Admitting Diagnosis: Dyspnea (Shortness of Breath)
Past Medical History: Lung Cancer with Metastasis to the Brain
Neurological System: Alert, confused, fatigue, hitting the nurse ever time they try to provide care.
Hearing: Uses hearing Aid
Eyes: Legally blind
Respiratory: Crackles and wheezing to chest
Cardiovascular: Normal heart sound. Legs swollen
Gastrointestinal: Has not had a bowel movement in 2 days. Decrease bowel sound to right upper and left lower quadrant. No nausea or vomiting. Lost 5 pounds in 2 weeks. Decrease appetite
Genourinary: Foul smelling concentrated urine
Musculoskeletal: Generalized weakness,
Sleep and rest: sleep 6 hours at night takes sleeping pill at home
Integumentary: Normal, warm to touch, bruising to right arm and left shoulder
Mobility: Able to ambulate, unsteady on feet, needs assistance to get to the washroom (30 marks)
Pain: Joint pain 8/10
Falls: Has had 2 falls in the past month
