.
SBAR 69 N.H
Scenario N.H., an 89-year-old widow, recently experienced a left-sided cerebrovascular accident (CVA). She has right-sided weakness and expressive aphasia with minimal swallowing difficulty. N.H. has a medical history of a minor left-sided CVA 2{1/2} years ago, chronic atrial flutter, and hypertension. She has lived with her daughter?s family in a rural town since her previous stroke. Since admission to an acute care facility 5 days ago, N.H. has gained some strength, has become oriented to person and place, and is anxious to begin her rehabilitation program. She is transferred for rehabilitation to your skilled nursing facility with the orders shown in the chart. Chart View Admission Orders
Hydrochlorothiazide 25 mg/day PO
Digoxin 0.125 mg/day PO
Warfarin (Coumadin) 5 mg/day PO
Acetaminophen 325 mg q6h PO prn for pain
Zolpidem (Ambien) 5 mg PO at bedtime prn for sleep
Diet: Mechanical soft, low sodium with ground meat
Foley catheter to gravity drainage, and then begin bladder training
Referrals for speech therapy, occupational therapy, and physical therapy to evaluate and treat swallowing, communication, and functional abilities
CASE STUDY PROGRESSA week later, at the interdisciplinary care conference, you report that bladder training is progressing and recommend removing the catheter if N.H.?s mobility and communication abilities have progressed sufficiently. The group and N.H. agree that she is ready for the Foley catheter to be removed
CASE STUDY PROGRESS Two days after the Foley catheter is removed, you observe that N.H.?s urine is cloudy and concentrated and has a strong odor, even though the volumes voided have been adequate
CASE STUDY PROGRESSN.H. is started on sulfamethoxazole 800 mg/trimethoprim 160 mg (Bactrim DS) 1 tab PO bid ? 10 days for a urinary tract infection (UTI). However, 2 days later, N.H. is in the bathroom and she is very upset. She has just voided; there is blood on the toilet, and the water is bright red with blood. You help the UAP clean N.H. and help her into bed
4. Describe your assessment steps.5. Identify at least 2 potential causes for N.H.?s hematuria.6. Using SBAR, what information would you provide to the physician when you call?
CASE STUDY PROGRESSN.H.?s physician changes her antibiotic to oral ciprofloxacin (Cipro) and holds the warfarin for 2 days. Two days later, N.H.?s UTI is responding to antibiotics and she has had no further bleeding in the urine. You want to prepare her and her daughter for eventual discharge.7. You have provided teaching about preventing a recurrent UTI to N.H. and her daughter. You use the Teach-Back technique to confirm understanding. Which statement by N.H.?s daughter indicates an adequate understanding of the information provided?
CASE STUDY OUTCOMEN.H.?s right-sided weakness and expressive aphasia do not resolve. Her daughter takes N.H. home and, with the help of her sister, nieces, and a home health aide, they have adjusted well to living together
SBAR 69
N.H
Scenario
N.H., an 89
–
year
–
old widow, recently experienced a left
–
sided cerebrovascular accident
(CVA). She has right
–
sided weakness and expressive aphasia with minimal swallowing
difficulty. N.H. has a medical history of a
minor left
–
sided CVA 2{1/2} years ago, chronic atrial
flutter, and hypertension. She has lived with her daughter?s family in a rural town since her
previous stroke. Since admission to an acute care facility 5 days ago, N.H. has gained some
strength, has b
ecome oriented to person and place, and is anxious to begin her rehabilitation
program. She is transferred for rehabilitation to your skilled nursing facility with the orders
shown in the chart.
Chart View
Admission Orders
Hydrochlorothiazide 25 mg/day PO
Digoxin 0.125 mg/day PO
Warfarin (Coumadin) 5 mg/day PO
Acetaminophen 325 mg q6h PO prn for pain
Zolpidem (Ambien) 5 mg PO at bedtime prn for sleep
Diet: Mechanical soft, low sodium with ground meat
Foley catheter to gravit
y drainage, and then begin bladder training
Referrals for speech therapy, occupational therapy, and physical therapy to evaluate and treat
swallowing, communication, and functional
abilities
CASE STUDY PROGRESSA week later, at the interdisciplinary care conf
erence, you report that
bladder training is progressing and recommend removing the catheter if N.H.?s mobility and
communication abilities have progressed sufficiently. The group and N.H. agree that she is ready
for the Foley catheter to be removed
CASE STU
DY PROGRESS
Two days after the Foley catheter is removed, you observe that
N.H.?s urine is cloudy and concentrated and has a strong odor, even though the volumes voided
have been adequate
CASE STUDY PROGRESSN.H. is started on sulfamethoxazole 800 mg/trimetho
prim 160 mg
(Bactrim DS) 1 tab PO bid ? 10 days for a urinary tract infection (UTI). However, 2 days later,
SBAR 69 N.H
Scenario N.H., an 89-year-old widow, recently experienced a left-sided cerebrovascular accident
(CVA). She has right-sided weakness and expressive aphasia with minimal swallowing
difficulty. N.H. has a medical history of a minor left-sided CVA 2{1/2} years ago, chronic atrial
flutter, and hypertension. She has lived with her daughter?s family in a rural town since her
previous stroke. Since admission to an acute care facility 5 days ago, N.H. has gained some
strength, has become oriented to person and place, and is anxious to begin her rehabilitation
program. She is transferred for rehabilitation to your skilled nursing facility with the orders
shown in the chart. Chart View Admission Orders
Hydrochlorothiazide 25 mg/day PO
Digoxin 0.125 mg/day PO
Warfarin (Coumadin) 5 mg/day PO
Acetaminophen 325 mg q6h PO prn for pain
Zolpidem (Ambien) 5 mg PO at bedtime prn for sleep
Diet: Mechanical soft, low sodium with ground meat
Foley catheter to gravity drainage, and then begin bladder training
Referrals for speech therapy, occupational therapy, and physical therapy to evaluate and treat
swallowing, communication, and functional abilities
CASE STUDY PROGRESSA week later, at the interdisciplinary care conference, you report that
bladder training is progressing and recommend removing the catheter if N.H.?s mobility and
communication abilities have progressed sufficiently. The group and N.H. agree that she is ready
for the Foley catheter to be removed
CASE STUDY PROGRESS Two days after the Foley catheter is removed, you observe that
N.H.?s urine is cloudy and concentrated and has a strong odor, even though the volumes voided
have been adequate
CASE STUDY PROGRESSN.H. is started on sulfamethoxazole 800 mg/trimethoprim 160 mg
(Bactrim DS) 1 tab PO bid ? 10 days for a urinary tract infection (UTI). However, 2 days later,
SBAR 71 G.W
Scenario G.W., a 34-year-old African American man, presents with increasing right knee swelling. He states that the swelling has gotten worse over the past two weeks and on presentation is now having difficulty ambulating. He reports taking over-the-counter ibuprofen 200 mg tablets at least 4 to 8 tablets per day for nearly 1 year for persistent back and knee pain. He has not seen his primary care physician (PCP) in nearly 2 years. G.W. also complains of weakness, fatigue, decreased urine output, and joint pain and stiffness. He also tells you that when he does urinate, it looks ?rusty.? His vital signs are as follows: BP 210/100, P 86, R 24, T 98.7? F (37.1? C)
CASE STUDY PROGRESSG.W. tells you that a few years ago he was diagnosed with high blood pressure, but he did not like the medication?s side effects, so he stopped taking it. He said that he was told that he had ?kidney problems? but never kept the appointments to check his kidneys. After further assessment, the nurse finds that the abdomen appears firm, round, and distended with edema. He has +2 edema on his ankles and shins bilaterally. He reports decreased urine output; on admission urine is dark and rust-colored. G.W. is alert and oriented to person, place, time and situation. He is lethargic but easily arousable and coherent. His blood work shows a BUN of 35 mg/dL (12.5 mmol/L), serum creatinine of 4.7 mg/dL (415 mcmol/L), albumin 1.2 g/dL (12 g/L), Hgb 7.1 g/dL (71 g/L) and Hct 23.5%. The results of his urinalysis are listed here: Chart View Urinalysis
Appearance Clear
Color: Rust
Odor: Aromatic
pH 6.2
Protein Positive
Glucose Negative
White blood cells 5
WBC casts Many
Red blood cells 10
RBC casts Many
CASE STUDY PROGRESS The nephrologist is consulted and the results of a renal biopsy confirm the diagnosis of chronic glomerulonephritis. G.W. received a furosemide (Lasix) drip, and had a total urine output of 450 mL in the next 24 hours. G.W.?s BP has improved but remains elevated at 198/102. The nephrologist ordered lisinopril 5 mg PO once daily, IV methylprednisolone (Solu-Medrol) and cyclophosphamide 2 mg/kg PO daily
CASE STUDY PROGRESS Orders for G.W. include fluid restriction and a ?renal diet.? The dietitian visits G.W. to discuss the changes to his diet
CASE STUDY OUTCOME After 3 days, G.W.?s creatinine and BUN remained elevated with continued hypertension, edema, and decreased urine output. He was started on hemodialysis for management of renal function and the Solu-Medrol was changed to PO prednisone. He remained in the hospital for 3 weeks before being transferred to a rehabilitation facility.
SBAR 71
G.W
Scenario
G.W., a 34
–
year
–
old African American ma
n, presents with increasing right knee
swelling. He states that the swelling has gotten worse over the past two weeks and on
presentation is now having difficulty ambulating. He reports taking over
–
the
–
counter ibuprofen
200 mg tablets at least 4 to 8 table
ts per day for nearly 1 year for persistent back and knee pain.
He has not seen his primary care physician (PCP) in nearly 2 years. G.W. also complains of
weakness, fatigue, decreased urine output, and joint pain and stiffness. He also tells you that
when
he does urinate, it looks ?rusty.? His vital signs are as follows: BP 210/100, P 86, R 24, T
98.7? F (37.1? C)
CASE STUDY PROGRESSG.W. tells you that a few years ago he was diagnosed with high
blood pressure, but he did not like the medication?s side effects,
so he stopped taking it. He said
that he was told that he had ?kidney problems? but never kept the appointments to check his
kidneys. After further assessment, the nurse finds that the abdomen appears firm, round, and
distended with edema. He has +2 edema
on his ankles and shins bilaterally. He reports decreased
urine output; on admission urine is dark and rust
–
colored. G.W. is alert and oriented to person,
place, time and situation. He is lethargic but easily arousable and coherent. His blood work
shows a
BUN of 35 mg/dL (12.5 mmol/L), serum creatinine of 4.7 mg/dL (415 mcmol/L),
albumin 1.2 g/dL (12 g/L), Hgb 7.1 g/dL (71 g/L) and Hct 23.5%. The results of his urinalysis
are listed here:
Chart View
Urinalysis
Appearance
Clear
Color:
Rust
Odor:
Aromatic
pH
6.
2
Protein
Positive
Glucose
Negative
White blood cells
5
SBAR 71 G.W
Scenario G.W., a 34-year-old African American man, presents with increasing right knee
swelling. He states that the swelling has gotten worse over the past two weeks and on
presentation is now having difficulty ambulating. He reports taking over-the-counter ibuprofen
200 mg tablets at least 4 to 8 tablets per day for nearly 1 year for persistent back and knee pain.
He has not seen his primary care physician (PCP) in nearly 2 years. G.W. also complains of
weakness, fatigue, decreased urine output, and joint pain and stiffness. He also tells you that
when he does urinate, it looks ?rusty.? His vital signs are as follows: BP 210/100, P 86, R 24, T
98.7? F (37.1? C)
CASE STUDY PROGRESSG.W. tells you that a few years ago he was diagnosed with high
blood pressure, but he did not like the medication?s side effects, so he stopped taking it. He said
that he was told that he had ?kidney problems? but never kept the appointments to check his
kidneys. After further assessment, the nurse finds that the abdomen appears firm, round, and
distended with edema. He has +2 edema on his ankles and shins bilaterally. He reports decreased
urine output; on admission urine is dark and rust-colored. G.W. is alert and oriented to person,
place, time and situation. He is lethargic but easily arousable and coherent. His blood work
shows a BUN of 35 mg/dL (12.5 mmol/L), serum creatinine of 4.7 mg/dL (415 mcmol/L),
albumin 1.2 g/dL (12 g/L), Hgb 7.1 g/dL (71 g/L) and Hct 23.5%. The results of his urinalysis
are listed here: Chart View Urinalysis
Appearance Clear
Color: Rust
Odor: Aromatic
pH 6.2
Protein Positive
Glucose Negative
White blood cells 5
SBAR 70 S.M
Scenario S.M. is a 68-year-old man who is being seen at your clinic for routine health maintenance and health promotion. He reports that he has been feeling well and has no specific complaints, except for some trouble ?emptying my bladder.? Vital signs at this visit are 148/88, 82, 16, 96.9? F (36.1? C). He had a complete blood count and complete metabolic panel completed 1 week before his visit, and the results are listed in the chart. Chart View Laboratory Test Results
Sodium 140 mEq/L (140 mmol/L)
Potassium 4.2 mEq/L (4.2 mmol/L)
Chloride 100 mEq/L (100 mmol/L)
Bicarbonate 26 mEq/L (26 mmol/L)
BUN 19 mg/dL (6.8 mmol/L)
Creatinine 0.8 mg/dL (72 mcmol/L)
Glucose 94 mg/dL (5.2 mmol/L)
RBC 5.2 million/mm3 (5.2 x 1012/L)
WBC 7400/mm3 (7.4 x 109/L)
Hgb 15.2 g/dL (152 g/L)
Hct 46%
Platelets 348,000/mm3 (348 x 109/L)
Prostate-specific antigen (PSA) 4.23 ng/mL (4.23 mcg/L)
Urinalysis Within normal limits
CASE STUDY PROGRESS While obtaining your nursing history, you record no family history of cancer or other genitourinary problems. S.M. reports frequency, urgency, and nocturia ? 4; he has a weak stream and has to sit to void. These symptoms have been progressive over the past 6 months. He reports he was diagnosed with a ?large prostate? a number of years ago. Last month, he began taking saw palmetto capsules but had to stop taking them because ?they made me sick.?
CASE STUDY PROGRESS The primary care provider (PCP) performs a digital rectal examination (DRE) and asks for a post-void residual (PVR) urine test
CASE STUDY PROGRESSS.M. returns in 6 months to report that his symptoms are worse than ever. He has tried several different medications, but medication management failed, and he is told that surgical intervention is necessary
CASE STUDY OUTCOMES.M. chose an outpatient procedure. He did well postoperatively and was discharged to home.
SBAR 70
S.M
Scenario
S.M. is a 68
–
year
–
old man who is being seen at your clinic for routine health
maintenance and health promotion. He reports that he has been feeling well and has no specific
complaints, except for some trouble ?emptying my bladder.? Vital signs at this visi
t are 148/88,
82, 16, 96.9? F (36.1? C). He had a complete blood count and complete metabolic panel
completed 1 week before his visit, and the results are listed in the chart.
Chart View
Laboratory
Test Results
Sodium
140 mEq/L (140 mmol/L)
Potassium
4.2 mEq/L (4.2 mmol/L)
Chloride
100 mEq/L (100 mmol/L)
Bicarbonate
26 mEq/L (26 mmol/L)
BUN
19 mg/dL (6.8 mmol/L)
Creatinine
0.8 mg/dL (72 mcmol/L)
Glucose
94 mg/dL (5.2 mmol/L)
RBC
5.2 million/mm3 (5.2 x 1012/L)
WBC
7400/mm3 (7.4 x 109/L)
Hgb
15
.2 g/dL (152 g/L)
Hct
46%
Platelets
348,000/mm3 (348 x 109/L)
Prostate
–
specific antigen (PSA)
4.23 ng/mL (4.23 mcg/L)
Urinalysis
Within normal limits
CASE STUDY PROGRESS
While obtaining your nursing history, you record no family history
of cancer or other ge
nitourinary problems. S.M. reports frequency, urgency, and nocturia ? 4; he
has a weak stream and has to sit to void. These symptoms have been progressive over the past 6
SBAR 70 S.M
Scenario S.M. is a 68-year-old man who is being seen at your clinic for routine health
maintenance and health promotion. He reports that he has been feeling well and has no specific
complaints, except for some trouble ?emptying my bladder.? Vital signs at this visit are 148/88,
82, 16, 96.9? F (36.1? C). He had a complete blood count and complete metabolic panel
completed 1 week before his visit, and the results are listed in the chart. Chart View Laboratory
Test Results
Sodium 140 mEq/L (140 mmol/L)
Potassium 4.2 mEq/L (4.2 mmol/L)
Chloride 100 mEq/L (100 mmol/L)
Bicarbonate 26 mEq/L (26 mmol/L)
BUN 19 mg/dL (6.8 mmol/L)
Creatinine 0.8 mg/dL (72 mcmol/L)
Glucose 94 mg/dL (5.2 mmol/L)
RBC 5.2 million/mm3 (5.2 x 1012/L)
WBC 7400/mm3 (7.4 x 109/L)
Hgb 15.2 g/dL (152 g/L)
Hct 46%
Platelets 348,000/mm3 (348 x 109/L)
Prostate-specific antigen (PSA) 4.23 ng/mL (4.23 mcg/L)
Urinalysis Within normal limits
CASE STUDY PROGRESS While obtaining your nursing history, you record no family history
of cancer or other genitourinary problems. S.M. reports frequency, urgency, and nocturia ? 4; he
has a weak stream and has to sit to void. These symptoms have been progressive over the past 6
SBAR 73 S.R
Scenario You are a registered nurse in the emergency department (ED). It is a hot summer day and S.R., a 25-year-old woman, comes to the ED with severe left flank and abdominal pain and nausea with vomiting. S.R. looks very tired, her skin is warm, and she is perspiring. She paces about the room doubled over and is clutching her abdomen. S.R. tells you the pain started early this morning and has been pretty steady for the past 6 hours. She gives a history of working outside as a landscaper and takes little time for water breaks. Her past medical history includes three kidney stone attacks, all occurring during late summer. Her abdomen is soft and without tenderness, but her left flank is extremely tender to touch. You place S.R. in one of the examination rooms and take the following vital signs: 188/98, 90, 20, 99? F (37.2? C). A voided urinalysis shows RBCs of 50 to 100 on voided specimen and WBCs of zero
CASE STUDY PROGRESS The noncontrast CT scan shows a left 2-mm ureteral vesicle junction stone
CASE STUDY PROGRESSS.R. was discharged with instructions to strain all urine and return if she experienced pain unrelieved by the pain medication or increased nausea and vomiting
CASE STUDY PROGRESSS.R. returns to the ED in 6 hours with pain unrelieved by the pain medication and increased blood in her urine. She is being held in the ED until she can be transported to surgery.
CASE STUDY PROGRESSA 2-mm calculus was removed by basket extraction. Pathologic examination reported the stone to be calcium oxalate.
CASE STUDY OUTCOMES.R. recovers from this most recent episode and continues to follow the protocol for fluid intake and dietary measures. One year later, she has yet to report a recurrence of stones
SBAR 73
S.R
Scenario
You are a registered nurse
in the emergency department (ED). It is a hot summer day
and S.R., a 25
–
year
–
old woman, comes to the ED with severe left flank and abdominal pain and
nausea with vomiting. S.R. looks very tired, her skin is warm, and she is perspiring. She paces
about the
room doubled over and is clutching her abdomen. S.R. tells you the pain started early
this morning and has been pretty steady for the past 6 hours. She gives a history of working
outside as a landscaper and takes little time for water breaks. Her past medi
cal history includes
three kidney stone attacks, all occurring during late summer. Her abdomen is soft and without
tenderness, but her left flank is extremely tender to touch. You place S.R. in one of the
examination rooms and take the following vital sign
s: 188/98, 90, 20, 99? F (37.2? C). A voided
urinalysis shows RBCs of 50 to 100 on voided specimen and WBCs of zero
CASE STUDY PROGRESS
The noncontrast CT scan shows a left 2
–
mm ureteral vesicle
junction stone
CASE STUDY PROGRESSS.R. was discharged with instr
uctions to strain all urine and return if
she experienced pain unrelieved by the pain medication or increased nausea and vomiting
CASE STUDY PROGRESSS.R. returns to the ED in 6 hours with pain unrelieved by the pain
medication and increased blood in her uri
ne. She is being held in the ED until she can be
transported to surgery.
CASE STUDY PROGRESSA 2
–
mm calculus was removed by basket extraction. Pathologic
examination reported the stone to be calcium oxalate.
CASE STUDY OUTCOMES.R. recovers from this most recent epis
ode and continues to follow
the protocol for fluid intake and dietary measures. One year later, she has yet to report a
recurrence of stones
SBAR 73 S.R
Scenario You are a registered nurse in the emergency department (ED). It is a hot summer day
and S.R., a 25-year-old woman, comes to the ED with severe left flank and abdominal pain and
nausea with vomiting. S.R. looks very tired, her skin is warm, and she is perspiring. She paces
about the room doubled over and is clutching her abdomen. S.R. tells you the pain started early
this morning and has been pretty steady for the past 6 hours. She gives a history of working
outside as a landscaper and takes little time for water breaks. Her past medical history includes
three kidney stone attacks, all occurring during late summer. Her abdomen is soft and without
tenderness, but her left flank is extremely tender to touch. You place S.R. in one of the
examination rooms and take the following vital signs: 188/98, 90, 20, 99? F (37.2? C). A voided
urinalysis shows RBCs of 50 to 100 on voided specimen and WBCs of zero
CASE STUDY PROGRESS The noncontrast CT scan shows a left 2-mm ureteral vesicle
junction stone
CASE STUDY PROGRESSS.R. was discharged with instructions to strain all urine and return if
she experienced pain unrelieved by the pain medication or increased nausea and vomiting
CASE STUDY PROGRESSS.R. returns to the ED in 6 hours with pain unrelieved by the pain
medication and increased blood in her urine. She is being held in the ED until she can be
transported to surgery.
CASE STUDY PROGRESSA 2-mm calculus was removed by basket extraction. Pathologic
examination reported the stone to be calcium oxalate.
CASE STUDY OUTCOMES.R. recovers from this most recent episode and continues to follow
the protocol for fluid intake and dietary measures. One year later, she has yet to report a
recurrence of stones
