SBAR

The RN is concerned about Sharon Kuhl, who was admitted for ankle surgery. Sharon has a history of bipolar disorder and her family suspects she hasn't been taking her Lithium. She is agitated, has low Lithium levels, and shows signs of a manic episode. The RN administered lorazepam and requests a continued one-to-one sitter, a PRN med for agitation, and a psychiatric consult for possible inpatient admission. The RN confirms the orders for the sitter, Haloperidol, and psychiatric consult. I'm the RN taking care of Sharon Kuhl, date of birth 3-15-93, in room 1. I'm calling because I'm concerned with her increased level of agitation. She came to us last night, was admitted for surgical repair of a right ankle fracture that was the result of falling off of a stage. She came to me around 11 o'clock this morning post-op with no complications during surgery or in recovery. She does have a past medical history of bipolar disorder and is prescribed Lithium 600 mg twice a day and lorazepam 1 mg every 8 hours PRN. This was confirmed by her regular psychiatrist after a consultation in the ED. As per her partner and sister, she has not been eating or sleeping for the past two weeks, which made them suspect she has not been taking her Lithium as prescribed. On assessment, vital signs are stable. Blood pressure is 134 over 70, heart rate is 88, respiration is 16, and a temperature of 37.2 degrees Celsius. She is oriented to self, however, does not know what day it is or the details of last night. She can, however, identify her partner at the bedside. She currently denies pain and is on a fentanyl PCA pump, however, states the medication makes her feel not herself and has threatened to remove her IV. The IV is still intact. The ED drew Lithium levels and they were 0.1. She's cooperative but agitated and is loud and verbal with grandiose ideas and thoughts, sleight of ideas, and making statements that she needs to get out of here. We did administer the PRN lorazepam to help calm her and we are waiting to see how she reacts to that. We do have a one-to-one sitter and given her history of non-adherence with her prescription medication and the low Lithium levels, I'm led to believe that Sharon is probably having a manic episode. I would like to make sure we have a continued order for the one-to-one sitter and an additional PRN med for agitation should the lorazepam not help. I do think she would benefit from more in-depth psych consult and possibly inpatient psych admission until her Lithium levels can reach a therapeutic level. Okay. So, just to confirm, there is an order for the continued one-to-one patient or one-to-one until the patient is deemed safe and then I have a new order for Haloperidol, 0.5 milligrams IV push once PRN for agitation. And I do have an order for the psychiatric consult with recommendation for inpatient hospitalization. I will report back and thanks for your help.