ISBAR
Question
Read the 'Clinical Article Download 'Clinical Article'
Complete an ISBAR Download ISBARusing ISBAR Download ISBAR(you may use one of these or another SBAR form of your liking)
Complete the Weekly Patient Care Summary Download Weekly Patient Care Summaryas thoroughly as possible (you will only have one patient, Mr. Smith, from the clinical article
Complete the fillable Concept Map Download fillable Concept Map with data gathered from the Weekly Patient Care Summary and SBAR
SUBMIT the following three completed items for clinical credit:
Completed SBAR
Completed Weekly Patient Care Summary
use the provided aploaded files to fill up for this assignement please.


Solution
Weekly
Patient Care Reflection/Patient Care Planning to be reviewed and discussed with
clinical faculty (Adopted
from Nurse Tim Inc):
Prioritize
the patient’s on your RN’s assigned team, briefly summarize the prioritization
1. regularly assess the
patient’s vital signs and initiate early interventions as needed.
2. Monitoring the patient’s
input and output.
3. Checking the patient’s
electrolyte levels and taking appropriate corrective measures.
4. Adjusting the patient’s
medications as needed to prevent further kidney damage.
5. Educating the patient
and family about the disease process and potential complications.
Priority
Patient brief overview (maintain HIPAA)
The 75-year-old patient
was admitted two days ago with respiratory distress and expanded edema in the feet.
The admission diagnosis has a history of biventricular HF (last ejection
fraction of 50%), obstructive pulmonary disease, atrial fibrillation, high
blood pressure, benign prostatic hypertrophy, type 2 diabetes, and stage 3
kidney disease is HF exacerbation. His blood pressure and heart rate have ranged
below normal ranges since admission. He has persisting hypokalemia and increased
creatinine levels (2.5mEq/L) and (GFR 45mL/min/1.73m2). Vital signs
are BP: 100/58mmHg, HR: 57b/min, RR: 22b/min (even and non-bored), SPO2:91% on
2L oxygen via nasal cannula. Blood glucose at 0630 was 100mg/dL
Priority
Problem:
Difficulty in breathing,
edema of both feet, decreased blood pressure (100/58mmHg), decreased PR
57b/min, increased creatinine, and reduced GFR.
Key
Assessment for Priority Problem:
Assess the patient vital
signs regularly to note the deviations from the normal ranges and initiate
early interventions.
Urea and electrolytes
tests should be carried out.
Labs/Diagnostics
for Priority Problem:
SPO2 91%
GFR:45mL/min/1.73m2
Creatinine levels is
2.5mEq/L
B-type natriuretic
peptide level (900 pg/mL)
Patient
Care Interventions/Rationale:
Administer oxygen
supplementation to ensure adequate oxygenation of the vital organs and body
tissues and prevent irreversible damage due to hypoxemia.
Hold the administration
of medications or reduce the doses to avoid further damage to the kidneys.
Monitor the input and
output
Actual/Potential
Problems:
Kidney failure and heart
failure



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