SOLVED33

James Jones, a 33-year-old client who experienced a fall at work and hit his head. The nurse has obtained vital signs, performed assessments, and implemented interventions. The nurse is now preparing to send the client to the OR. To complete this activity: Review the data in the client’s chart. Open the SBAR tab. Based on the information in the client’s chart create an SBAR note to give to the client’s OR nurse. Be sure to fill in all of the textboxes. James Jones Male, 33 years MRN: 8502236 Attending: Michael Smertka, MD Allergies: Code Status: Full Code Comments: none EXPAND Patient Summary Primary Concern: Traumatic Brain Injury Vital Signs 02/26/2024 0028 02/26/2024 0048 02/26/2024 0118 Heart Rate 58 89 102 Blood Pressure 100/70 98/65 90/64 Respirations 12 18 26 Temperature 98.3 (Oral) 98.9 (Oral) 99.4 (Oral) SpO2 (%) 98% 97% 95% Pain 9 9 10 Allergies Allergy Date Noted Reaction Orders Type of order to view: All Search: Show 10 entries Previous 1 Next Start Date Order Details Status All 02/26/2024 0043 5% DEXTROSE IN WATER (D5W) Written order Dose/Frequency: Continuous Rate: 100 mL/hour Route: IV Start Date: 02/26/2024 0043 End Date: 02/26/2024 0028 – Given Active 02/26/2024 0043 ACETAMINOPHEN Written order Dose/Frequency: 650 mg Every 4 Hours Route: Rectal Start Date: 02/26/2024 0043 End Date: 02/26/2024 0028 – Given PRN as needed for mild to moderate pain Active 02/26/2024 0043 Comprehensive Metabolic Panel (CMP) Written order Frequency: Now Start Date: 02/26/2024 0043 Active 02/26/2024 0043 Computerized Tomography (CT Scan) Written order Frequency: Stat Start Date: 02/26/2024 0043 CT of head with contrast Active 02/26/2024 0043 Diet-NPO Written order Frequency: Continuous Start Date: 02/26/2024 0043 Active 02/26/2024 0043 Elevate HOB Written order Frequency: Continuous Start Date: 02/26/2024 0043 30 to 45 degrees Stabilize neck Active 02/26/2024 0043 PROMETHAZINE HYDROCHLORIDE Written order Dose/Frequency: 25 mg Every 6 Hours Route: Intramuscular Start Date: 02/26/2024 0043 End Date: 02/26/2024 0028 – Given PRN Nausea Active 02/26/2024 0119 Transfer Order Set-(details in comments, Meds & IVs are separate orders) Written order Start Date: 02/26/2024 0119 TRANSFER TO: Surgery DIAGNOSIS: Traumatic brain injury with subdural hematoma CONDITION: Guarded Active 02/26/2024 0043 Vital Signs with Neuro Checks Written order Frequency: Other-See Administration Instructions Start Date: 02/26/2024 0043 Every 15 minutes Active Showing 1 to 9 of 9 entries Previous 1 Next Labs Lab Range 02/26/2024 0103 Chemistry Glucose (mg/dL) adult: fasting 60-110 mg/dL; adult nonfasting: 60-140mg/dL. Newborn >40-45 mg/dL 105 Urea nitrogen (BUN) (mg/dL) 8-20 mg/dL Creatinine (mg/dL) 0.7-1.3 mg/dL Bun/Creatinine Ratio Sodium 136-145 mEq/L 140 Potassium (mEq/L) 3.5-5 mEq/L 3.6 Chloride 98-106 mEq/L 106 Calcium 8.7 – 10.7 mg/dL Magnesium (mEq/L) 1.5-3 mEq/L Phosphate 2.5-4.5 mg/dL Total CO2 (mEq/L) 23-29 mEq/L 24 AST (SGOT) (units/L) 3-44 units/L Alkaline phosphatase (ALP) (U/L) 36-92 U/L Total Protein (g/dL) 6.3-8.2 ALT (SGPT) (units/L) 0-40 units/L Albumin (g/dL) 3.5-5.5 g/dL Bilirubin: Total (mg/dL) 0.3-1.2 mg/dL Total Calcium (mg/dL) <10 days: 7.6- 10.4 mg/dL Umbilical: 9.0 - 11.5 mg/dL 10 days - 2 years: 9.0 - 10.6 mg/dL Child: 8.8 - 10.8 mg/dL Adult: 9.0 - 10.5 mg/dL (Decreases with age) Serum bicarbonate (HCO3) Adult/child: 21-28; Newborn/infant: 16-24 (mEq/L) James Jones Male, 33 years MRN: 8502236 Attending: Michael Smertka, MD Allergies: Code Status: Full Code Comments: none EXPAND Patient Information Name James Jones Sex Assigned at Birth Male Gender Identity Male Pronouns Pronouns DOB 33 years Provider Michael Smertka, MD Code Status Code Status Comments Chemistry Glucose (mg/dL) 105 Urea nitrogen (BUN) (mg/dL) Creatinine (mg/dL) Bun/Creatinine Ratio Sodium 140 Potassium (mEq/L) 3.6 Chloride 106 Calcium Magnesium (mEq/L) Phosphate Total CO2 (mEq/L) 24 Imaging/Diagnostic Te SCIENCE HEALTH SCIENCE NURSING

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