Instructions
Complete an audio or audio/video recording of your handoff report in an appropriate format for a patient that is being transferred to a higher level of care. The report needs to be no more than 5 minutes long and can be in an SBAR (situation, background, assessment & recommendation), PACE (patient/problem, assessment/actions, continuing changes & evaluation), or MBAR (medication, background, assessment & recommendation) format. Any of these formats can be adapted for handoff reports. You must include all pertinent information that will ensure a safe transfer. You can record it as a file on a separate device and upload it to the course or record directly in the specific area of the course utilizing the ârecordâ function. Be sure to complete the readings for this module before attempting to complete this assignment as there is important information related to handoff report that will assist you with this assignment.
Review the data on Millie Larsenâs unfolding case study here from last week (Module 5) and this week (Module 6). Complete an audio or audio/video recording of your handoff report in an appropriate format for a patient that is being transferred to a higher level of care. The report needs to be no more than 5 minutes long and can be in an SBAR (situation, background, assessment & recommendation), PACE (patient/problem, assessment/actions, continuing changes & evaluation), or MBAR (medication, background, assessment & recommendation) format. Any of these formats can be adapted for handoff reports. You must include all pertinent information that will ensure a safe transfer.
Millie Larsen Update
Millie has been hospitalized for several days now and has developed a fever of 102 F with some productive coughing and difficulty breathing. She is also complaining of some pleuritic chest pain when she tries to take a deep breath. Her respiratory rate has increased to 26 breaths per minute, and her heart rate is 60, blood pressure is 98/66 mm Hg, O2 saturation is 90% on 6 L/min oxygen via nasal cannula. When the nurse assessed Millieâs lung sounds, she heard rhonchi and scattered crackles. A chest X-ray was obtained, and Millie is diagnosed with hospital-acquired pneumonia. A complete blood count was drawn, and the results show that Millieâs white blood cell count is 22,000.
New orders have been obtained from the provider, and Millie is to be transferred to a Special Care Unit (SCU) to monitor her condition more closely.
New orders include:
Obtain sputum specimen and blood cultures.
Oxygen at 6 Liters high flow nasal cannula to keep O2 sat at or above 92%
Normal saline intravenous solution at 100 mL/hr
Ciprofloxacin (Cipro) 400 mg intravenous mini bag every 12 hours
Acetaminophen 650 mg oral every 6 hours prn for fever greater than 101F
Tramadol hydrochloride 50mg (oral) every 4-6 hours PRN for pain
Albuterol respiratory nebulizer treatments q 4 hours and prn
Respiratory monitoring per acute protocol
Blood and sputum cultures have been obtained, normal saline is infusing, and the first dose of ciprofloxacin (Cipro) was given. She was given a respiratory treatment by the RT and has not received any pain medication at this time. Millie still has a Foley catheter in place, and her urinary tract infection has resolved, but the provider still wants to strictly monitor her intake and output. Millie is lethargic and appears very ill and still is not eating well or taking in oral fluids as the provider would like. Her intake has only been 300 mL IV fluids, 50 mL oral intake plus sips, and output of 200 mL clear yellow urine.
You are the RN to transfer Millie to the Special Care Unit (SCU) and will be giving a handoff report to the receiving RN.
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