Question Neurological: The patient is alert and oriented to person, place,… Neurological:The patient is alert and oriented to person, place, time, and situation. Pupils are equal and reactive.Pain:He complains of abdominal pain that he rates as a 9 out of 10. He grimaces and moans with any movement and states the pain is worse when you try to reposition him in bed. When asked about his pain, he describes it as a constant aching pain that becomes stabbing when he tries to move.Cardiac:The patient’s apical pulse is regular; no murmurs or clicks are auscultated. Radial, pedal, and tibial pulses are weak at 1-plus. Capillary refill is less than 3 seconds. No edema noted.Respiratory:Breath sounds are clear throughout. Respirations are regular and shallow.Gastrointestinal:The patient’s abdomen is firm, with active bowel sounds in all quadrants. The patient complains of pain upon light palpation and guarding is present. Patient states his last bowel movement was Thursday.Skin:Appears dry with tenting present and is pale and cool to the touch. Oral mucous membranes and gums are pale and dry.[STUDENT ACTION: Document your assessment findings.]The nurse who will be assuming care of Mr. Biller is now ready for report. You provide an SBAR patient report, taking care to include the preparations for surgery and the patient’s concerns.[STUDENT ACTION: Document SBAR communication with the preoperative nurse assuming care for Mr. Biller Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
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