Provide SBAR nursing note on this case study The Emergent Care…
Provide SBAR nursing note on this case study
The Emergent Care ClinicThe Emergent Care Clinic is a fast-paced, 20-bed, free-standing, acute care facility. The Emergent Care interdisciplinary team includes registered nurses (RN), practical nurses (PN), unlicensed assistive personnel (UAP), physicians, advanced practice registered nurses (APRN), and other collaborative care team members. The facility is located in an urban area and is open for business 24 hours a day, 7 days a week.The first action of the charge nurse for the day shift in the Emergent Care Clinic is to prepare the assignments for the day shift. In addition to the charge nurse, three RNs, one PN, and two UAPs are scheduled from 7 am to 7 pm.
The RN admits Mr. Jackson to a clinic room and connects him to the continuous cardiac telemetry monitor so that his heart rhythm can be monitored in the room and at the nurse’ station.The UAP assists the RN in getting Mr. Jackson admitted.The UAP obtains Mr. Jackson’s vital signs and reports the results to the RN. Reported vital signs for Mr. Jackson are as follows:T 98.8° F, P 94 beats/min, R 30 breaths/min, BP 158/88 mmHg. The UAP applies the continuous pulse oximeter to Mr. Jackson’s finger. The client’s Oxygen saturation is 90%. The RN applies an automated blood pressure cuff to assess his BP every 15 minutes.Mr. Jackson also reports dull, aching pain from his left shoulder radiating to his left arm. He states the pain comes and goes, and he rates the pain as 5 on a pain scale of 0 to 10. The RN applies electrodes from the ECG machine to obtain a tracing of Mr. Jackson’s heart function and then analyzes Mr. Jackson’s ECG strip, which shows a normal sinus rhythm.Mr. Jackson informs the nurse that he does not take any prescription medications and is not now on any over-the-counter medications or vitamin supplements. He says that he just returned from a long business trip overseas. Furthermore, he states that he has had no previous health problems.After oxygen is applied to Mr. Jackson, his oxygen saturation improves to 96% with respirations of 22. The RN draws blood for laboratory analysis, starts an IV saline lock, and calls the UAP to prepare the client for a 12 lead ECG.The RN notes that Mr. Jackson is now having occasional premature ventricular contractions (PVCs). The primary HCP prescribes a potassium supplement and sublingual nitroglycerin. Potassium chloride 40 mEq PO Stat is prescribed. The supply is potassium chloride 20 mEq per tablet. The charge nurse notes that Mr. Jackson’s primary RN has pulled four tablets from the automated medication delivery system.The primary RN gives the correct dose of the medication. After being treated with the potassium and nitroglycerin, Mr. Jackson rates his pain as a 0 on a scale of 0 to 10. His vital signs are stabilized, and his oxygen is discontinued. The RN teaches him about signs and symptoms of electrolyte imbalance and the importance of staying hydrated while traveling. Mr. Jackson is discharged with a referral to a cardiologist for an outpatient stress test later that afternoon.The next day, the nurse manager of the clinic plans a staff meeting with the nurses and UAPs to communicate some changes in the scheduling protocol for the clinic.The nurse manager conducts the meetings and presents two different protocols for scheduling. The staff nurses and UAPs vote on the two different options.The participative style of leadership is usually the most effective, but there may be times when other styles are more appropriate.During the staff meeting, the nurse manager asks the nurses and UAPs to provide feedback about the daily operations of the clinic. One of the full-time RNs states, “I am always assigned the most challenging clients in the clinic, and it isn’t fair.”After hearing the RN’s response, the nurse manager schedules a one-on-one meeting with the RN to investigate the issue. After the meeting, one of the PNs tells the nurse manager that there is reason to believe one of the nurse practitioners is stealing narcotics.When asked about the specifics of the accusation, the PN states that the nurse practitioner was observed taking out five pre-filled vials of morphine from the automatic drug dispenser and placing them in her pocket. The nurse manager investigates and determines that five vials of morphine sulfate were removed from the automatic drug dispenser using the nurse practitioner’s login identification (ID), but no clients had prescriptions for morphine on this shift.The nurse practitioner admits to stealing the narcotics. The nurse manager accompanies the impaired nurse to the employee assistance program office. After counseling, the impaired nurse voluntarily admits herself to a drug rehabilitation unit.Just before the change of shift, Billy Young, a 6-year-old boy, is brought to the clinic by his grandmother, Ms. Washington. The charge nurse asks Ms. Washington what happened to Billy. The grandmother states that Billy fell out of his swing and that she thinks he broke his arm. The charge nurse observes Billy holding his right arm, but he is not crying and is currently playing with a toy car.Billy’s grandmother states that she is the child’s legal guardian, and she gives her consent for him to be treated. The RN asks Ms. Washington if she has any proof of legal guardianship for Billy. Ms. Washington shows the charge nurse her custody papers for Billy. The charge nurse assigns a male RN with 5 years pediatric experience to care for Billy.Billy’s grandmother states that she has had custody of him since he was a baby and his biological mother visits him about once a month. In the examining room, the RN helps Billy take off his shirt and notices that he has bruises in multiple stages of healing on his back. The nurse asks Billy how he got the injuries, and Billy says, “I don’t know.” The grandmother states, “He falls a lot.”The nurse completes the rest of the assessment and notices what appear to be cigarette burns on the back of Billy’s legs. Billy does not cry when his injured arm is assessed. The nurse assigns a UAP to stay with Billy while he notifies the primary HCP.The HCP calls the grandmother out of the room to ask her a few questions while the RN interviews Billy alone. When asked again about his injuries, Billy says his mother gets mad sometimes when he is not good. Billy says he tells his grandmother, but she doesn’t do anything. When the RN reports Billy’s statements to the HCP, the HCP states, “I have known this family for a long time and I do not believe what the child is saying.”The RN notifies the nurse manager of the situation and requests help with the problem. CPS is notified since the nurse is ethically and legally bound to report child abuse. The HCP’s behavior is also reported. After CPS and social services are notified, Billy receives treatment for his arm by another HCP. He is discharged to the care of a social worker for the night.Nurse managers have many responsibilities. One of those responsibilities is ensuring the Emergent Care Clinic’s performance improvement (PI) plan is implemented.As part of the PI plan, the nurse manager reviews trends in client satisfaction surveys. It is noted that 76% of clients are dissatisfied with the amount of time they had to wait in the waiting room.Upon completion of the root cause analysis, the nurse manager determines that the lengthy wait time is due to the manual processing and duplication of paperwork. After the nurse manager reviews different computerized data systems to help solve this problem, a recommendation is made that a system be purchased as soon as possible. The nurse manager plans to ensure a smooth transition and continuity of care for all clients when the clinic purchases a computerized data system for billing, charting, and medication administration.
Majority of the staff agrees that an electronic data system will allow them to make more efficient use of their time and improve client satisfaction. The system is purchased for all departments in the Emergent Care Clinic.