SBAR: Situation-Background-Assessment-Recommendation
Student Name Date
Before filling out the template, first save the file on your computer. Then open and use that version of the tool. Otherwise, your changes will not be saved.
Template: SBAR about (End of Shift Report)? • Identify self, unit, patient, room number. • Briefly state the problem, what Is it, when it happened or started, and how severe.
Hi I am nurse …., 49 y/o female, T.C., admitted to unit from the postanesthesia care unit (PaCU) after an exploratory laparotomy, is in room …..
vi a
Situation: What Is the situation you are calling
3 weeks ago underwent a vaginal hysterectomy and right salpingo- oophorectomy for abdominal pain and endometriosis. Postoperatively, she experienced an intraabdominal hemorrhage, requiring transfusion with 3 units of packed red blood cells (RBCs).
d
S
sh ar e
After discharge, she continued to have abdominal pain, chills, and fever. She was readmitted twice: first for treatment of postoperative infection and second for evacuation of a pelvic hematoma. Despite treatment, T.C. continued to have abdominal pain, chills, fever, and nausea and vomiting. Dr. Jersey has placed post-op orders and directions on when to call her.
• •
A
•
Most recent vital signs Lab results: provide the date and time test was done and results of previous tests for comparison Other clinical information
•
Code status
Assessment: Whal is the nurse's assessment of the situation?
VS: BP 130/70 P 94 RR 16 Temp: 99.7 F (37.6 C) SpO2 93% with oxygen 2L by nasal cannula Pain is an 8 on a scale of 1 to 10. NKDA
as
related to the situation could include the following: • The admitting diagnosis and date of admission • List of current medications, allergies, IV fluids, and labs
w
Background: Pertinent background information
Receiving an IV of 1000 mL D5.45NS at 100 mL/hr in her left forearm, with no swelling or redness.
s ur tu se dy H er res o. ou co rc m e
B
Receiving IV morphine sulfate for pain control through a patient-controlled analgesia (PCa) pump. The settings are dose 2 mg, lock-out interval 20 minutes, 4hour maximum dose of 30 mg,
Respirations are shallow and her Spo2 is 93% with oxygen at 2 L by nasal cannula. A respiratory rate below 12 would indicate that T.C. is hypo-ventilating. T.C might require Narcan. Monitoring for respiratory depression is crucial when receiving morphine.
Th
is
Easily aroused and oriented to place and person, dozes between verbal requests. She has a low-midline abdominal dressing that is dry and intact and a JacksonPratt drain that is fully compressed and contains a scant amount of bright red blood, foley to down drain has clear yellow urine
This study source was downloaded by 100000805705997 from CourseHero.com on 10-20-2021 01:41:35 GMT -05:00