Author Question: You check his VS, with these results: blood pressure (BP) 98/60; P 120; R 24 . you note he is ... (Read 109 times)

karlynnae · **on:** Jun 25, 2018

you check his VS, with these results: blood pressure (BP) 98/60; P 120; R 24 . you note he is restless and
slightly confused. The pulse oximeter reads 86, so you start him on 6 L O2 by nasal cannula (NC).

you
identify faint crackles in the posterior bases bilaterally. The heart monitor on lead II shows nonspecific T
wave changes.
Using SBAR, what information, based on the findings, would you provide to the physician
when you call?
What will be an ideal response?

Question 2

you perform a neurovascular assessment and note the following findings: Left foot pale, temperature
slightly cooler than right foot. Right foot color pink. Capillary refill less than 3 seconds on both sides.

edema +1 on left foot and lower leg; no edema on right leg. dorsalis pedis palpable on both feet. Sensation
equal on both sides. Able to dorsiflex feet and rotate ankles freely. Rates pain in left femur as a 5 out of 10.
Your institution uses electronic charting. Based on the assessment in the previous paragraph,
which of the following systems would you mark as abnormal as you document the
neurovascular assessment? For abnormal findings provide a brief narrative note.
X Abnormal
Skin color:
Skin temperature:
Capillary refill:
Edema:
Peripheral pulses:
Sensation:
Motor function:
Pain:
What will be an ideal response?

wtf444 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Following SBAR (Situation, Background, Assessment, Recommendation), you would first identify
yourself, then explain that M.M. is complaining of right-sided chest pain and is restless. For
background, state that M.M. is postoperative day 2 after ORIF of a fractured left femur. Give current
VS and details of his respiratory examination findings, including lung sounds, skin color, level of
consciousness (LOC), and any other assessment items that have changed and the time period of
those changes. Let the physician know that you have started oxygen at 6 L by NC because his Spo2
reading was 86, and that the ECG monitor shows nonspecific T wave changes and tachycardia.
The assessment of the situation is that M.M. is experiencing an embolism, either a fat embolism or a
pulmonary embolism. You would anticipate diagnostic testing, initiation of anticoagulant therapy,
respiratory support, and transfer to an intensive care unit (ICU).

Answer to Question 2

Skin color: Left foot pale, right foot pink
Skin temperature: Left foot slightly cooler than right foot
Capillary refill:
Edema: Presence of +1 edema left foot and lower leg
Peripheral pulses:
Sensation:
Motor function:
Pain: Rates pain as 5 out of 10