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Jody Rush, 20 YO Female; SBAR,SOAP NOTE AND CAREPLAN
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Jody Rush, 20 YO Female; SBAR,SOAP NOTE AND CAREPLAN
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Jody Rush, 20 Y/O Female; SBAR,SOAP NOTE AND CAREPLANJody Rush, 20 y/o female, admitted for right femur fracture status post skiing accident. She is in a
traction splint, and will be going for surgical repair today. Vital signs are BP 120/62 P 88 R 20 T 98.9 F,
37.2 C, PaO2 99. She has been in a lot of pain, and has been receiving 25 mcg IVP, q2 hours Fentanyl for
pain. She was nauseated after her last Fentanyl dose, and the Dr. Ordered an additional 4mg IVP, Zofran.
She has a history of exercise induced asthma, and uses a rescue inhaler, Albuterol. Her parents are on
their way; they are flying in today. She was on a ski trip with some of her friends from college; her best
friend has been camped out with her. We were able to get her on a bed pan earlier, but it took a lot of
work. We just received an order for a foley catheter. There was some concern that she may have
sustained a head injury as she has an abrasion to her forehead, but she denies ever losing
consciousness. Patients affected extremity has normal pulses, and the capillary refill is less than 3
seconds.
an SBAR , SOAP AND A CAREPLAN FOR PT BELOW
General: Jody rush 20 y/o female
CC: admitted for right femur fracture status post skiing accident.
SOAP:
Subjective
, • Patient complains pain
• Patient complains nausea
• Denies ever losing consciousness
Objective
• Patient is in a traction splint, and will be going for surgical repair today.
• She has abrasion on her forehead
Assessment
• Vital signs: BP 120/62 , P 88, R 20, T 98.9, 37.2 C, Pa02 99.
• Patient affected extremity has normal pulses, and
• Capillary refill is less than 3 seconds
Plan
• Wash hand and provide patient privacy. Per CDC protocol and patient advocacy
• Complete full assessment, to include capillary refill and pedal pulses. To establish a
baseline, and to ensure there is no occlusion
• Medicate as needed for pain. As pain is minimized, it is easier for the patient to
move.
• Encourage positioning, turning, coughing, and deep breathing post operatively.
Initiate incentive spirometry, and then hourly there after. To prevent lung atelectasis
• Orient friend in room to provide assistance with incentive spirometry to patient
hourly. To maximize patient compliance.
SBAR:
Situation: This is nurse X calling from medical surgical ward. I am calling about Jody
Rush . The problem is the patient goes into electrical mechanical disassociation (EMD) with
no palpable pulses. CPR is initiated, and the patient is intubated. The interventional
Radiologist attempts to place a femoral guided catheter to provide thrombolysis of the
pulmonary embolism of the pulmonary embolism, but is unsuccessful. CPR continues for
60-90 minutes while they attempt to set up an extracorporeal membrane oxygenation
(ECMO)
Background: The patient was admitted for right femur fracture status post skiing accident.
They performed an open reduction internal fixation (ORIF) with two plates and eight screws.
Her dressing is fry and intact. She has good sensation in her operative leg, and can wiggle
her toes. Her VS normal, and her Foley catheter is draining clear urine. She has an 18-
gauge IV Cath to left forearm that anesthesia started in the OR. The IV is running at
125ml/hr. She has Ancef, 1gm ordered. The nurse is trying to get her to use her incentive
spirometer.
Assessment: Jody is more awake, but has become anxious. The surgeon called
respiratory therapist to give nebulizer but the treatment does not relive her shortness of
breath, but her lungs are clear bilaterally. Jody becomes very short of breath and panicked
as she is preparing to go into CT scanner. She tells the nurse she cant breath, and
becomes inconsoble. Her Pa02: 88, R 30, BP 140/80, P 128.
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