Rapid Assessment of a Client (reply)
When first discovering Mr Johnson, I would yell for help, for someone to activate the emergency response protocol.
I would quickly wash my hands and put on a pair gloves. While waiting for help to arrive I would assess if Mr Johnson is breathing, if he has a pulse, then complete a full set of vitals. I would talk to Mr Johnson to see if he can be easily woken, perform a chest rub if needed and assess his pupils for reaction to light. Next, I would assess how Mr Johnson is lying. What is his position? Are there any obvious signs of injury from his fall? Is he safe in his current position on the floor until help arrives? I may need to reposition an arm or leg if they ended up in an unnatural position from his fall or move any equipment that may have fallen, making the loud crash that alerted me to his room in the first place. I would probably place a nasal cannula on 2 liters of oxygen as well. If Mr Johnson woke up I would ask him what happened to assess his orientation and cognition. I would assess for pain, dizziness, check for facial symmetry, hand grip strength, clarity of his speech and sensation of all extremities (Jarvis, 2016). If Mr. Johnson does not wake up, once help arrived we would carefully place him back into his bed together, probably using a bed sheet. If Mr. Johnson wakes up and denies dizziness, I would first help him to a sitting position and take another set of vitals. I would assess for pain and dizziness with the position change or a change in vitals. If Mr. Johnson appears stable, with help of another clinician, we could help him into a chair. Once in the chair another set of vitals, assessment of pain or dizziness. Hopefully, in the chair, Mr. Johnson’s current vitals and condition is stable enough that with assistance he can be pivoted back into bed. Once back in bed, with rails up and in the lowest position for safety with call light in reach I could leave him long enough to get his chart and a phone to call the Dr with if I didn’t already have it with me. If possible, I would have a nurse’s aide stay with him while I went to gather any supplies I thought I would need. In this scenario, the classmate I am giving report to could be the Dr.
S-Situation- Mr. Johnson experienced an unwitnessed fall on the way the bathroom with loss of consciousness.
B-Background- Mr. Johnson was admitted yesterday with the diagnosis of cerebral vascular accident. He also has a long standing history of hypertension, hyperlipidemia and unexplained syncopic episodes.
A-Assessment- Mr. Johnson woke with a chest rub and was disoriented as to what happened. Pt complains of pain on the back of his head 6\10, HR 110, BP 85\45, T 97.8, R 20. Pupils PERRLA, equal hand grips, speech clear, hand grips equal, denies numbness or tingling in any extremity, reports dizziness that resolved within 3 minutes. Pt was assisted to sitting position with vitals as follows, pain in head 6\10, HR 100, BP 95\54, T 97.8, R 20, reports dizziness that resolved within 2 minutes. Pt pivoted into bed with hands on assistance. Once in bed pt’s vitals as follows, pain in head 4\10, HR 95, BP 100\55, T 97.8, R 20. Pt assessed Q15 min x 4. Most recent set just prior to this report as follows, pain in head 2\10, HR 82, BP 110\65, T 97.8, R 18. Pt states, “I don’t know what happened. I felt fine then all of a sudden woke up on the floor with all of you standing around me.”
R-Recommendation- I will continue to monitor Mr. Johnson’s vitals and neuro assessment, but would you like him to have an EKG or any lab work to assess his status further? I will notify you of results and any changes in neuro status or vitals. Is there anything else you would like updated on?
SBAR report format referenced from Center for Learning and Innovation, Pro Health Care, RN to Physician SBAR Examples.
Jarvis, C. (2016). Physical Examination and Health Assessment (7th ed.). Canada: Elsevier Inc.