SOLVED339

Mr. O., was admitted to your facility’s surgical unit following a major gastric resection. He performed his preoperative preparation at home and reportedly was in good spirits while on the way to the OR. His vital signs on admission were BP 122/82 mm Hg, temperature 37 °C (98.6 °F), heart rate 70, respirations 12, and oxygen saturation 98%. Mr. O. received IV morphine in the Operating Room to prevent immediate pain. Since then, he has received other pain-relieving injections; he consistently asks for them more frequently than they are ordered. He is becoming restless and irritable and says he feels “shaky.” He has slept about 3 hr in the past 24 hr, once waking up after a nightmare. You are assigned to care for Mr. O. When you enter his room, he is irritable and demanding. His face is flushed, and he complains of severe pain, although it has been only 2 hr since his last pain medication. He begins crying when talking about the pain. Mr. O.’s vital signs are now BP 152/92, temperature 38 °C (100.4 °F), HR 104, respirations 20, and oxygen saturation 90%. When you took his blood pressure, you noticed his hand was shaking. He complained that the “cuff was too tight.” He also says his “insides feel shaky all over” and his “chest hurts.” He says he feels nauseated and has a “terrible headache.” Write a SBAR note for this client?
SCIENCE
HEALTH SCIENCE
NURSING

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