Assessment For Patient With Heartburn And Chest Discomfort Assignment
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Write My Essay For MeChoose an experience from your nursing practice. Using the template, explain the situation in detail, followed with background information. Then explain your immediate assessment and recommendations you have for the provider.
Include the following in the template:
Be sure to include three or four evidence-based references, not older than 5 years.
When giving your recommendation, discuss how you would educate the client using evidence-based research and guidelines. Include how you would adhere to ethical research standards to improve patient outcomes and clinical practice.
I have included the SBAR chart in the files that I have already started. Please add to this chart to enhance it and complete recommendation with sources. Assessment For Patient With Heartburn And Chest Discomfort Assignment
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SBAR Assignment
| Situation | This is RN calling from 6 North.
I am calling about 70-year-old male patient Larry Stone in room 6716. The problem I am calling about is Mr. Stone reporting heartburn and chest discomfort while presenting with low blood pressure (BP 80/64) and tachycardia (HR 180)Assessment For Patient With Heartburn And Chest Discomfort Assignment. I am concerned about his sudden changes in vital signs and chest discomfort. |
| Background | Mr. Stone was admitted today as full code with left eye blindness, swelling, discharge, and pain after being hit in the eye with a tree branch three weeks ago. He was diagnosed with cellulitis. He was also treated three weeks ago for sepsis.
Mr. Stone does not have any medical history and no home medications. The patient has not received any imaging during this admission. His recent admission blood work was all within normal range. Current vital signs are: BP 80/64, HR 180’s, RR 20, Temp 100.7, O2 sat 88 on room air. He is currently on lactated ringers at 125 mL/hr. Vancomycin and Cefepime are scheduled to start at 0400. He is not on telemetry monitoring. Mr. Stone received a PRN dose of acetaminophen 3 hours ago for a headache. |
| Assessment | Mr. Stone is alert and oriented x4. He has reported continuous vision loss and pain in his left eye. All other neurological signs are within normal limits. His chest discomfort is described as palpations and heartburn, which he states is alleviated by taking deep breaths. His skin is clammy, and he is observed to be shaking. From my assessment, I am concerned about possible sepsis, ophthalmological issues, and arrhythmias. |
| Recommendation | I recommend an immediate evaluation of Mr. Stones. A cardiac workup, including an electrocardiogram (ECG) and cardiac enzymes, should be done to evaluate for possible myocardial infarction or arrhythmias due to his chest discomfort, tachycardia, and low blood pressure. An ophthalmological consultation should be obtained to evaluate for any worsening of the cellulitis or other eye-related complications. We should also consider starting Mr. Stone on a broad-spectrum antibiotic, given his recent history of sepsis and current presentation of possible sepsis, adhering to the World Health Organisation (2022) guidelines for sepsis management. Timely administration of antibiotics is essential in reducing the mortality rates associated with sepsis (Im et al., 2022)Assessment For Patient With Heartburn And Chest Discomfort Assignment. In the meantime, Mr. Stone should be placed on continuous cardiac monitoring, and supplemental oxygen should be initiated to maintain oxygen saturation above 95%.
I also recommend patient education, including explaining to Mr. Stone and his family the significance of his current symptoms and the need for immediate evaluation and treatment. Kim and Park (2019) note that early recognition and management of sepsis can improve patient outcomes, including reducing mortality rates. Education should also be provided on the importance of adhering to the prescribed antibiotic regimen to prevent the development of antibiotic-resistant infections. During the process, it is important to adhere to ethical research standards to improve patient outcomes and clinical practice. This includes obtaining informed consent for any interventions or procedures and ensuring that patients and their families are fully informed about the risks and benefits of treatment (Gossman et al., 2022). Patient privacy and confidentiality must be maintained throughout care. |
| References | Gossman, W., Thornton, I., & Hipskind, J. E. (2022, June 11). Informed consent. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430827/
Im, Y., Kang, D., Ko, R.-E., Lee, Y. J., Lim, S. Y., Park, S., Na, S. J., Chung, C. R., Park, M. H., Oh, D. K., Lim, C.-M., Suh, G. Y., Lim, C.-M., Hong, S.-B., Oh, D. K., Suh, G. Y., Jeon, K., Ko, R.-E., Cho, Y.-J., & Lee, Y. J. (2022). Time-to-antibiotics and clinical outcomes in patients with sepsis and septic shock: A prospective nationwide multicenter cohort study. Critical Care, 26(1). https://doi.org/10.1186/s13054-021-03883-0 ORDER NOWKim, H. I., & Park, S. (2019). Sepsis: Early recognition and optimized treatment. Tuberculosis and Respiratory Diseases, 82(1), 6–14. https://doi.org/10.4046/trd.2018.0041 World Health Organisation. (2022). Sepsis. Www.who.int. https://www.who.int/health-topics/sepsis#tab=tab_ Assessment For Patient With Heartburn And Chest Discomfort Assignment |
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