Assignment: Choose an experience from your nursing practice when you assessed for normal and abnormal physiology related to the HEENT systems
Assignment: Choose an experience from your nursing practice when you assessed for normal and abnormal physiology related to the HEENT systems
SBAR for HEENT
Communication is an essential component needed for the delivery of safe and high-quality care. Effective communication can be achieved using tools such as SBAR. SBAR is a communication tool used in healthcare to inform healthcare providers about the health status of the patients and recommend care interventions. Therefore, the purpose of this paper is to present SBAR for a client with HEENT condition.
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Situation
Hello Dr. Liz. This is nurse X from the surgical floor. I am calling in relation to Mr. John the 54-year-old patient that was admitted to the unit one day ago. The patient was involved in a road accident and admitted to the unit for monitoring for any complications from the mild injuries he suffered from the incident. The patient’s vital signs have deteriorated in the last ten minutes, which warrants the need for a rapid intervention.
Background
Mr. John is a 54-year-old patient that was admitted to the unit a day ago for stabilization after being involved in a road accident. The patient suffered soft tissue injury in the left lower limb and lacerations on the head. A head CT scan had been performed and was unremarkable. The additional assessments performed at the time of admission and afterwards had ruled out other complications such as fractures and internal hemorrhage. The patient has been stable since the beginning of the shift. The vitals taken over the last 10 minutes were as follows: BP 118/78, T 36.7, RR 20 breaths per minute, regular SPO2 96%, and P 78. Ten minutes later, the client started being restless. The vitals taken at this were as follows: P: 62, RR 13 breaths per minute, irregular, BP 132/82, SPO2 90, and T 36.6. The patient is currently restless, tachypneic, with shallow breathing pattern.
Assessment
Given this data, I am concerned that the patient may be experiencing increased intracranial pressure. The symptoms that include changes in his behavior, bradycardia, bradypnea, and widening systolic blood pressure demonstrate an impending case of increased intracranial pressure(Changa et al., 2019; Tripathy & Ahmad, 2019). In addition, the patient’s history of a road accident implies his increased risk of developing increased intracranial pressure from the head trauma that he suffered.
Recommendation
I have already initiated the patient on oxygen to enhance body tissue perfusion and respiratory support. The patient is also on continuous monitoring. I recommend that we do a stat head CT scan to rule out increased intracranial pressure and anticipate intracranial surgery. Would it be okay if an order for a head CT scan be done and you assess the patient immediately? Do you agree? I will educate Mr. John using evidence-based research and guidelines. One of the areas in health education will be measures to avoid precipitating factors for increased intracranial pressure such as lifting weight, forceful coughing or sneezing, and soft diet to minimizing straining with bowel movement. The patient should also be educated about the importance of avoiding Valsalva Maneuver and sudden head movements (Changa et al., 2019).
I will adopt l strategies to adhere to ethical research standards to improve patient outcomes and clinical practice. One of them is seeking informed consent. I will obtain informed consent from the patient before initiating any treatments. Informed consent will ensure the promotion of patient’s autonomy in the treatment process. The other strategy is ensuring privacy and confidentiality of the patient’s data. Data integrity should be maintained in the patient’s treatment process. Unauthorized parties should not access the data. The healthcare providers should also seek informed consent from the patient before sharing their data with others. I will also make decisions that minimize harm while optimizing on benefits. This would be crucial to ensure non-maleficence and beneficence. I will make decisions that prioritize the patient’s interests(Martins et al., 2020). I will make decisions based on best available evidence to ensure outcomes such as safety, quality, and efficiency in the care process. I will also incorporate patient’s values, needs, and preference in the treatment to adopt interventions that align with his expectations.
Conclusion
This paper has explored SBAR for a client with head injury. The SBAR provides accurate information about the patient’s current health status, which inform the decisions that should be adopted.Ethical standards and guidelines will inform the decisions that I make when addressing the patient’s needs.Therefore, SBAR is crucial for care coordination and delivery of care that enhances care outcomes.
References
Changa, A. R., Czeisler, B. M., & Lord, A. S. (2019). Management of Elevated Intracranial Pressure: A Review. Current Neurology and Neuroscience Reports, 19(12), 99. https://doi.org/10.1007/s11910-019-1010-3
Martins, V., Santos, C., & Duarte, I. (2020). Bioethics education and the development of nursing students’ moral competence. Nurse Education Today, 95, 104601. https://doi.org/10.1016/j.nedt.2020.104601
Tripathy, S., & Ahmad, S. R. (2019). Raised Intracranial Pressure Syndrome: A Stepwise Approach. Indian Journal of Critical Care Medicine : Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine, 23(Suppl 2), S129–S135. https://doi.org/10.5005/jp-journals-10071-23190
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Choose an experience from your nursing practice when you assessed for normal and abnormal physiology related to the HEENT systems: head, eyes, nose, ears, and throat. Using the “NUR-643E SBAR” 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 “NUR-643E SBAR” template:
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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.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center
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Assignment: Choose an experience from your nursing practice when you assessed for normal and abnormal physiology related to the HEENT systems
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