Question TEMPLATE FOR PRE-CONFERENCE PRESENTATIONS ON ASSIGNED PATIENTS… TEMPLATE FOR PRE-CONFERENCE PRESENTATIONS ON ASSIGNED PATIENTS (Jared Griffin)Who is my client? (for example: age, marital status).? Patient’s initials? Patient’s sex and gender? Patient’s age? Admission dateState significant events of this hospitalization (admitting diagnosis, surgery, emotional crises, fracture).? Admission reason? Pertinent medical and surgical historyMedical HxSurgical Hx=What are your major concerns for this patient today?Reason for seeking care (history of present illness) .? Paint a picture of the patient’s problem(s), including:? Discussion of the pathophysiologyDiscussion of how the medical and surgical history impacts the current problem(s) Impact on normal body function Signs and symptoms (and rationale for those signs and symptoms) Important laboratory and diagnostic exam results and the significance Discuss Common complications experienced because of your patient’s problem(s)5. Patient’s current treatment plan (Discuss diet, activity, medications, therapy, etc.)Discuss the nursing plan of care for your patient - What will you focus on? What are your key safety considerations for the day?PATIENT’S DATALocation: Orthopedic unit 1555SBAR report from day shift nurse:Situation: Mrs. Jacobson is an 85-year-old white female who was admitted last evening after falling and fracturing her hip. X-rays have been taken and show left intertrochanteric hip fracture. Mrs. Jacobson is scheduled for surgery tomorrow.Background: Mrs. Jacobson has a 10-year history of osteoporosis, and her daughter reports that recently Mrs. Jacobson has been having dizzy spells.Assessment: Mrs. Jacobson’s vital signs are stable. Her pain is under control with morphine every 4 hours, and I medicated her at 1400. Her pain level was 2 after the morphine. The skin is intact; color and sensation around the hip area are within normal limits. A Morse Fall Scale assessment was completed on admission, and her score was 45. Fall precautions were implemented.Recommendation: You will need to reposition Mrs. Jacobson as she needs to be turned every 2 hours. You should perform a focused musculoskeletal assessment, reinforce safety, and provide patient education on fall risk. Assess her pain level and medicate for pain if needed. (Vsim Online) Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
