Provide SOAP or SBAR nursing note on this patient three days ago,…Provide SOAP or SBAR nursing note on this patient three days ago,…

Question Answered step-by-step Provide SOAP or SBAR nursing note on this patient three days ago,… Provide SOAP or SBAR nursing note on this patientthree days ago, at around 0630 hours, Dr. Douglas slipped and fell while she was alone at home. She felt a sharp pain and knew something was wrong. She couldn’t get to her phone, so she held still and waited for her husband to come home. At 0800 hours, Dr. Douglas reported at our Emergency Department with pain in her groin and inability to support weight. She had an open reduction and internal fixation at 1200 hours. At 1700 hours that day, she was moved here to Med-Surg for post-operative care. The physician has prescribed her 1 hydrocodone/acetaminophen tablet (5 mg hydrocodone and 325 mg acetaminophen) every 4-6 hours for post-operative pain, to be increased as needed up to 2 tabs every 4-6 hours. Physician also prescribed her apixaban for anticoagulation, at 2.5 mg twice a day, and she’s been given thromboembolic deterrent hose (known as a TED hose). Dr. Douglas has been receiving regular physical therapy. Her vital signs are all within normal limits. Her respirations are 15 per minute and her oxygen saturation is 98%. And now for the provider’s orders. Administer the hydrocodone as scheduled. Every four hours, monitor fluid input and output. Perform peripheral neurovascular checks every 8 hours until discharge. Provide ice as needed. Incentive spirometer 10 times per hour while awake. Check SpO2 every 8 hours and as needed to keep oxygen saturation over 92%. Notify the MD if there’s a significant increase in O2 needs. Keep dressing dry and notify MD if there’s significant drainage. Dr. Douglas will need to perform weight-bearing exercises with physical therapy, and go from bed to chair at least 2 times per day.The dressing is clean and Dr. Douglas’s skin shows no sign of infection. Dr. Douglas is stable, alert and oriented x4. Color, pulse, warmth, pain, sensation, and movement in extremities are all within normal limits. No disproportionate swelling. Strength of active movement against moderate resistance was last rated as 4 out of 5.Dr. Douglas’s pain is under control with medication. Her pain was last reported as 2 out of 10. Pain at the worst was reported as an 8 out of 10.Dr. Douglas is going to need help with her physical therapy exercises. She’s at risk for falls, so you’ll be helping with ambulation and self-care, too. Depending on her pain, you may also need to help with positioning throughout the day. Dr. Douglas has a PT session this morning at 0630 hours, and the MD will change her dressing at 0800 hours. Her husband, Jeffrey, is scheduled to visit at 1400 hours today.When you do your hourly check-in, I recommend that you perform musculoskeletal, strength, and skin checks, and monitor respiratory status. Monitor fluid input and output and perform neurovascular checks as ordered. You’ll want to perform mental status checks every 4 hours with orientation x4. Since Dr. Douglas is on pain medication, I recommend that you assess her pain before and after her physical therapy.  Health Science Science Nursing RN NUR2811-D Share QuestionEmailCopy link Comments (0)