Case Study: Communicating Accurate Information in a Care Situation

You are a new nurse working on a cardiac step-down unit. Eva Schmidt is a 76-year-old patient who was admitted 4 days ago with a diagnosis of congestive heart failure. She was transferred to your step-down unit from the cardiac intensive care unit (CICU). This is your first day working with her and her second day on the unit. Mrs. Schmidt mentions to you how much better she is feeling since she is finally getting some “good food.” She tells you the food on your unit is great compared with the “cardboard” tasting food in CICU. She describes the breakfast that she had this morning (scrambled eggs with ham and cheese) and last night’s “delicious” dinner. You notice that her weight is up 2.2 pounds from her weight on admission to your unit and that she has 2+ pitting edema in her feet and ankles. You check her diet order and it is for a “regular diet.” You are the nurse calling the physician to update the patient’s status to avert future complications. You think that an oral diuretic (water pill) is indicated because Mrs. Schmidt’s blood pressure is rising, her weight is up, pitting edema is present, and she has had no diet or fluid restrictions.

Questions

  1. Use SBAR or any other handoff method you are familiar with, to communicate this information to the physician.

Case Study: Communicating Accurate Information

Case Study: Communicating Accurate Information in a Care Situation

You are a new nurse working on a cardiac step-down unit. Eva Schmidt is a 76-year-old patient who was admitted 4 days ago with a diagnosis of congestive heart failure. She was transferred to your step-down unit from the cardiac intensive care unit (CICU). This is your first day working with her and her second day on the unit. Mrs. Schmidt mentions to you how much better she is feeling since she is finally getting some “good food.” She tells you the food on your unit is great compared with the “cardboard” tasting food in CICU. She describes the breakfast that she had this morning (scrambled eggs with ham and cheese) and last night’s “delicious” dinner. You notice that her weight is up 2.2 pounds from her weight on admission to your unit and that she has 2+ pitting edema in her feet and ankles. You check her diet order and it is for a “regular diet.” You are the nurse calling the physician to update the patient’s status to avert future complications. You think that an oral diuretic (water pill) is indicated because Mrs. Schmidt’s blood pressure is rising, her weight is up, pitting edema is present, and she has had no diet or fluid restrictions.

Questions

  1. Use SBAR, or any other handoff method you are familiar with, to communicate this information to the physician.

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