Clinical Assessment Preparation

CPNE Study Guide

SBAR (Situation- Background- Assessment- Recommendation) The student will be presented with a case scenario and patient data, and is to use their nursing judgment to determine the procedure to be performed for the application of sterile technique nursing simulation lab. Smith, John DOB : 6-1-70 MR : 0115678 Date : 3/7/17 Time: 1630 Situation: Events leading to hospitalization: Mr. Smith was admitted to the hospital yesterday for surgical debridement of a non-healing venous stasis ulcer to his right lower leg. Backgrou d: History of Hypertension, Venous Insufficiency, Diabetes Mellitus Type Two, Coronary Artery Disease, paraplegia due to swimming accident three years ago, and urinary retention due to history of BPH. A peripherally inserted catheter (PICC) line was inserted 7 days ago for intravenous administration of antibiotics. Assessment (pertinent to situation): Mr. Smith has been drinking water and eating solid foods with no complaints of nausea at present. He was constipated for two days, but this morning, he did have a formed bowel movement. The patient is awake, alert, and oriented to person, place, and time. Patient gets out of bed to chair with assistance x 1 with no c/o weakness but is noted to have balance issues. Patient was unable to void and required intermittent urinary catheterization. Twenty minutes ago, the patient voided 200 mL of clear yellow urine with an estimated post void residual of 150 mL. Patient has a wound with a dressing to the right lower extremity. The nurse practitioner changed the dressing at 0600 today. The wound bed looks red with granulation, no odor noted, surrounding skin is dry, and intact. Patient does report pain at the surgical site between rating it an 8 on the verbal rating pain scale. Patient has a PICC line in the left upper extremity. Last dressing change was on 3/3/17. Dressing is dry and intact, with no redness or swelling at the insertion site.

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