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Pulmonary Embolus Case Study

Terms in this set (20)

Following SBAR (Situation, Background, Assessment, Recommendation), you would first identify yourself, and then explain that S.K. is complaining of dyspnea and chest pain. For background, state that S.K. is postoperative day 3 after ORIF of left fibula and tibia and bilateral wrist fractures. Give current vital signs and details of his respiratory examination findings, including lung sounds, skin color, and any other assessment items that have changed and the time period of those changes. The assessment of the situation is that S.K. is experiencing a PE. You would anticipate diagnostic testing and the initiation of anticoagulant therapy and respiratory support.
My Answer:
S: Hello Dr., This is Savannah a LPN in the orthopedic unit taking care of SK. SK is showing signs of respiratory distress and states that his chest hurts and he cannot breathe.
B: SK is a 51 year old male and was admitted 3 days ago after a 15 foot fall off of a roof. He sustained bilateral fractures to his wrists and an open fracture to the left tibia and fibula. He had open reduction and internal fixation (ORIF) surgeries for all of his fracture, and is recovering in the orthopedic unit.
A: SK is diaphoretic, tachypneic, and has circumoral cyanosis. His apical heart rate is 110bpm. Lung sounds are diminished in the lower left lobe. SK is also agitated and dyspneic.
R: I would recommend a CT scan of the thoracic cavity for SK, along with ABG draws to determine the cause of the respiratory distress and treat it appropriately