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.

Communicating Accurate Information in a Care Situation

SBAR (Situation, Background, Assessment, Recommendation) is an effective method for communicating information to physicians or other healthcare professionals. Here’s how you can use SBAR to communicate the information about Mrs. Schmidt to the physician:

Situation:

  • Patient’s name: Eva Schmidt
  • Age: 76
  • Diagnosis: Congestive heart failure
  • Current unit: Cardiac step-down unit
  • Day of admission: 4 days ago
  • Previous unit: Cardiac Intensive Care Unit (CICU)
  • Patient’s statement: Mrs. Schmidt mentions feeling better and enjoying the food on our unit compared to the CICU.

Background:

  • Mrs. Schmidt’s admission diagnosis is congestive heart failure.
  • She has been on our unit for 2 days.
  • Weight on admission to our unit was [mention her weight].
  • Current weight is up by 2.2 pounds.
  • She has 2+ pitting edema in her feet and ankles.
  • Diet order: Regular diet.

Assessment:

  • Blood pressure is rising.
  • Weight gain of 2.2 pounds since admission.
  • Presence of 2+ pitting edema in feet and ankles.
  • Mrs. Schmidt describes enjoying meals with ham and cheese, indicating she might not be following dietary restrictions.

Recommendation:

  • Considering the rising blood pressure, weight gain, and edema, it appears that Mrs. Schmidt might be retaining fluid.
  • Suggest initiating an oral diuretic to manage the fluid overload and alleviate these symptoms.
  • Review and possibly modify her diet to adhere to fluid and sodium restrictions.
  • Request an evaluation of her medication regimen to ensure optimal management of congestive heart failure.

By using the SBAR method, you can effectively convey the patient’s situation, background information, your assessment findings, and your recommendations to the physician, facilitating clear and concise communication for appropriate patient care.

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