[Solved]: Earl James SBAR Assignment 2/12/25 Clinic…

Earl James SBAR Assignment 2/12/25 Clinic Assignment Earl James, 68-year old retired geologist, arrived to the ER with his daughter. He is well known to the ER team due to frequent visits. He has a 40-year history of smoking a pack of cigarettes per day with occasional cigars. He is 6 feet tall, 146 pounds, and appears malnourished. He is widowed and lives alone. He has difficulty managing his daily activities and seems more depressed than usual on this visit. For the past week he has experienced increased dyspnea and cough. He has been unable to care for himself. On observation his personal hygiene appeared to have deteriorated. He stated that he has been unable to get his breath or inhale deep enough to cough up secretions. He complained of mild nausea without abdominal pain or vomiting. His PCP had given him an unknown oral antibiotic 3 days ago. Mr. James was diagnosed with COPD 6 years ago and had an acute myocardial infarction 2 years ago. His pulmonary function test last year revealed severe airway obstruction and air trapping. He was discharged from the hospital 9 weeks ago where another PFT on discharge showed a decrease in his forced expiratory volume in 1 second from of predicted one year ago to of predicted 9 weeks ago. Upon discharge 9 weeks ago, he was sent home on 1.5 lpm O 2 with an ABG of: pH , and PaO 264 mm Hg . He received an influenza vaccine 2 months ago and a pneumococcal vaccine 2 years ago. According to his daughter, his physical activity has decreased in the last few months and is very minimal now. He spends most of his time watching TV, smoking and napping. All of his children have tried to convince him to move into a facility that can help him with daily living but he wants to stay home and take care of himself. His physician has recommended pulmonary rehabilitation but he has refused that as well. He has also denied having healthcare workers routinely provide services or check on him in his home. Assess: Barrel Chest, Clubbing of fingers and toes, pitting edema ( +2 ) around ankles, labored breathing, purse-lipped breathing, using accessory muscles, appears weak, frequent weak cough, large amounts of thick, yellow sputum, BP 190/115, HR 125, RR30, Temp 37 C, tactile fremitus was present over both lung fields, hyperrseonant percussion notes were produced bilaterally, bilateral wheezes heard. On room air his ABG : , and PaO 243 . His SpO 2 is . His CBC values were normal except for a hematocrit of . His attending physician ordered a respiratory care consult with a note that “all efforts should be made to keep the patient off the ventilator.” chest x-ray: with severe hyperinflation, depressed hemidiaphragms, and normal heart size Patient is admitted. Complete an SBAR for Mr. James: S: B: A: