Health Insurance Portability and Accountability Act
SCENARIO OVERVIEW:
Maggie Naganashe is a 62-year-old American Indian female with chronic renal failure. She also has a 15-year history of type II diabetes mellitus and a history of hypertension, and hyperlipidemia. She lives on an American Indian reservation and is a proud member of the Odawa tribe. Mrs. Naganashe reports that she was unable to go to her dialysis treatment this week because her husband had to use their only car for a job interview. She was admitted for shortness of breath, swelling, weight gain and fatigue.
You are the staff nurse at the hospital who will be conducting a comprehensive assessment. After completing your assessment, you are expected to document your findings as a nurse’s note in SBAR format.
• As the nurse, you are expected to complete the case scenario using the following tabs: EHR, History, Physical, Analyze, Actions, Nursing Notes, Summary
• There are required questions and/or additional information provided related to this case. The questions, information, and videos must be completed/reviewed prior to progressing to the next tab.
• Nursing Notes: At the end of the simulation, you will document your assessment findings using ISBAR.
CONFIDENTIALITY:
To preserve the educational value, integrity, and safety of the learning environment, you agree to maintain strict confidentiality about the proceedings of the simulation session, details of the training scenarios and the performance of all participants. You acknowledge that this expectation aligns with the guidelines related to the Health Insurance Portability and Accountability Act (HIPAA) as well as laws governing Protected Health Information (PHI) in client care environments. You will not view,
Sample Solution
SBAR Format Nurse's Note
Situation
Maggie Naganashe, a 62-year-old American Indian female with chronic renal failure, was admitted for shortness of breath, swelling, weight gain, and fatigue. She was unable to go to her dialysis treatment this week because her husband had to use their only car for a job interview.
Full Answer Section
Background Mrs. Naganashe has a 15-year history of type II diabetes mellitus and a history of hypertension and hyperlipidemia. She lives on an American Indian reservation and is a proud member of the Odawa tribe. Assessment Vital signs:- Temperature: 98.6° F (37° C)
- Pulse: 110 beats per minute
- Respiratory rate: 28 breaths per minute
- Blood pressure: 180/110 mmHg
- Oxygen saturation: 92% on room air
- Naganashe is alert and oriented to person, place, and time.
- She is in moderate respiratory distress.
- Her lungs are crackles bilaterally.
- Her lower extremities are edematous.
- Her skin is warm and dry.
- Blood urea nitrogen (BUN): 100 mg/dL (normal: 7-20 mg/dL)
- Creatinine: 7.0 mg/dL (normal: 0.8-1.5 mg/dL)
- Potassium: 5.5 mEq/L (normal: 3.5-5.0 mEq/L)
- Admit Mrs. Naganashe to the nephrology unit.
- Initiate dialysis treatment.
- Monitor her vital signs and respiratory status closely.
- Administer diuretics and antihypertensive medications as prescribed.
- Provide education to Mrs. Naganashe and her family about the importance of dialysis treatment and adherence to her medication regimen.