Receive Report From Explained for Students (Easy Guide)

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Key Explanation

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Original Question

You receive report from the offgoing nurse regarding your patient in room 509 Mr. Stephen Opako is a 82 year old, full code, with no known drug allergies. He is A&O x4, but only speaks French. He transferred to your SNF – Kings Court, 3 days ago (6/16/2021) after being admitted to the hospital 4 days ago (6/15/2021) after experiencing a recent fall. Hospital XRAY confirm he has rib fractures and a pelvic fracture, which will require nonsurgical treatment. Mr. Opako has been experiencing a great deal of pain, and has considerable bruising on his entire left side. He was found down at home, where he had lay for 3 days before his daughter Trixie came to check on him. Before going into Mr.Opako’s room you check his MAR and see he is due for his PO Metformin (to be taken with meals) and over hear your coworker say Mr.Opako’s breakfast tray is on its way. You also note his next 10mg PO Oxycodone is not due until another 5 hours, and he has no other PRN or scheduled pain medications available at this time. Upon your assessment of Mr.Opako his vital signs are LA BP 145/83, 98.6F, 17 RR, O2 is 98% on RA, when asked about his pain level he looked at you with a blank stare, however you noticed him holding and guarding his ribs and groin throughout your assessment. His lung sounds were clear. His brief was wet, so upon changing him you noticed a pink, non-blanching sore on high right buttocks. You attempted to turn Mr.Opako on his left side but he began yelling in french and pound his fists against the wall, pushing himself onto his back as he grit his teeth. He begins yelling at you in French and waving his hands motioning you to get out of his room. You decide you need to call the Doctor, so you begin writing our your SBAR.

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