Isbarr Assignment - How to give report using ISBAR PDF

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How to give report using ISBAR...

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I-SBAR-R Scenario Assignment

5 POINTS (See rubric below)

Outcome 6: Employ the National Patient Safety Goals in demonstration of safe nursing skills. G. Consistently use effective hand-off communication which includes the following: Up-to-date information regarding the patient’s condition, care, treatment, medications, services, and any recent or anticipated changes. Outcome 8: Demonstrate collaboratively with other team members using open professional communication in the planning, decision making, problem solving, goal setting, and assumption of responsibilities.

Directions:

1. Read chapter 7 in your Leadership Nursing Care management. 2. Develop an I-SBAR-R for 5 of the scenarios as assigned. Label each part of your SBAR 3. Answer the ‘Self-Reflective Questions’ As determined by instructor the student will be asked to present one scenario followed by discussion. SCENARIO 1: YOU ARE THE RN PREPARING TO CALL HOSPITALIST WHOM IS NOT FAMILIAR WITH PATIENT PATIENT SUMMARY: John Slightlytrue, 63 year-old, male, diagnosis: Syncope, admitted today at 1900 to medical-surgical unit. ADULT ADMISSION: Patient’s perception of problem: dizzy and light-headed at home today and almost fell. History: MI 2010 and HF 2012. Admitted from ED. Wife: Susan. Non-smoker. Weight 250 lb, 5’ 9”. CHART REVIEW: 04/10/2015 office visit Dr. Smith, Cardiologist, Essentia Health, Duluth, MN HOME MEDS: Metoprolol 25 mg oral daily – taken today, Lasix 20 mg oral daily – taken today, ASA 81 mg oral daily – taken today Ibuprofen 600 mg oral every six hours PRN for chronic back pain – taken over last 3 months TEST RESULTS REVIEW: Na 128, WBC 8,000, Plts 250,000, Cr 0.8, Hgb 10.0, U/A - negative ASSESSMENT FLOWSHEETS ON ADMISSION TO UNIT: VS 98.7 90 20 95% RA. 138/84; WDL = neurological (comment - denies dizziness), respiratory, cardiac, abdominal, peripheral vascular (comment – trace edema ankles bilaterally), and skin. I/O - Reports x1 dark stool today. NURSES NOTE: Dr. Zanter, Hospitalist, paged to notify of patient’s arrival on unit. Awaiting Dr. Zanter to see patient. LDA - IV infiltrated. 20 G saline lock restarted in R forearm. At 1930, CNA told Ben, RN, that John had been helped off commode, had large, black tarry stool, and was reporting not feeling well. Ben, RN, came to bedside and collected following data: VS 94/66 97.8 114 24 93%, pale, clammy, and patient reports “Don’t feel well and can’t get comfortable.” “Can I have something for my belly?” “It is really hurting.” Abdomen is soft, distended. Pain throughout all quadrants, 6/10.

SCENARIO 2: YOU ARE THE SUE, RN, GIVING REPORT TO THE HOSPITALIST, NURSE FROM ICU, AND CHARGE NURSE, WHOM HAVE RESPONDED TO THE RAPID RESPONSE, AND ARE NOT FAMILIAR WITH PATIENT PATIENT SUMMARY and ADULT ADMISSION: Mary Somewhattrue is a 72 year-old female admitted with CP, Possible MI to cardiology unit six hours ago. She is retired school teacher whom lives alone with dog, Ginger. When shoveling snow after the big storm, she developed a crushing sensation in her chest. This is not the first time she has had chest pain. She has a history of angina. She took an Aspirin and one Nitro and drove herself to the ED. MAR: Aspirin 81 mg oral daily – administered today Nitroglycerin 0.4 mg SL one tab every 5 minutes up to 3 tablets for chest pain – administered at 2205, 2210, 2215 Lopressor 25 mg oral daily – administered today TEST RESULTS REVIEW: Na 146, Cr 2, CPK - negative on admission, Troponins-I negative through 6 hours, Cardiac echo pending, EKG on admission - slight ST elevations. ASSESSMENT FLOWSHEETS (1600): WDL = neurological, respiratory, cardiac, abdominal, peripheral/vascular, skin. Cardiac monitor is NSR 60. LDA: NS; TKO. VS: 98.6 60 20 94% RA 120/80. At 2200, Mary puts on the call light. Sue, RN, responded. Mary reports pain at 9/10, sharp, left arm and nausea. VS 99.0 120 36 labored 85% room air saturations 90/52. There is no relief in the chest pain with nitro and BP decreased to 80/52. Per protocol, Sue administered oxygen at 2L/Min per NC and saturations improved to 91%. Mary is anxious and reports feeling terrible. Sue initiated a Rapid Response. The hospitalist, charge nurse, and a nurse from ICU respond.

SCENARIO 3: YOU ARE THE RN PROVIDING SHIFT REPORT TO THE ONCOMING RN PATIENT SUMMARY: Margie Unbelievable, 25 year-old primipara. PHYSICIAN NOTE: Induction started at 0600, dilated and delivered at 0830. Requested no epidural. Low forceps delivery of a 9 pound, 2 ounce, full-term male, 39 weeks. Apgar score 10/10, X 3 small, non-repaired tears. Although this was an unplanned pregnancy, Margie and her husband adjusted to the idea, and are now very excited parents. Margie plans to breast feed the baby. 98.6 90 20 99% RA, 130/62; Hgb 15.6 at clinic visit, POSTPARDUM ASSESSMENTS (45 minutes after the delivery): VS 98.2 88 16 98% RA 100/60, fundus is firm and is at level of umbilicus, no clots observed, continuous trickle of bright red lochia, no change in perineal edema, ice pack in place and peripads just changed. The peripads and chux weight indicate 300 mL of blood loss.

POSTPARDUM ASSESSMENTS AT 1430: WDL = neurological, respiratory, cardiac, abdominal, peripheral vascular, skin. Psychosocial X = comment: did not attend prenatal classes. Education: Father needs reinforcement changing diapers and burping baby. Fundus is massaged and remains firm at umbilical level and midline. A constant trickle of bright red lochia persists with no clots expressed. Peripads and chux weighed showing an additional 200 mL blood loss. I/O 650 urine, 100% lunch. VS 90/52 98.2 110 20 93% room air saturations. Pain: 4/10, perineum, aches at 1430. Breastfeeding: not latching well and feeding 5” on each side. Baby: TDAP pending, circumcision planned for 0800 tomorrow. Consent pending. MAR: Cymbalta 30 mg oral daily PRNs -Tylenol #3 one tablet, oral every 4 hours, Ibuprofen 600 mg oral every 6 hours – given at 1430, and Tylenol 650 mg oral every 4 hours – given at 1430 TEST RESULTS REVIEW: Admission CBC and BMP- WNL, Hgb in AM, HPV negative, U/A slight ketones.

SCENARIO 4: YOU ARE THE ADNS PROVIDING BEDSIDE REPORT TO THE ONCOMING RN PATIENT SUMMARY: Nancy Fairytale, 35 year-old female admitted 09/04/15 for diverticulitis. PHYSICIAN NOTE (1800 09/07/15): POD #3 bowel resection, VS: 99.0 74 24 93% RA 120/82. ABDOMEN: midline staples intact, wound clean, + bowel sounds, + flatus, tolerating clear liquids. LABS: Hgb 10.0. NURSES NOTE (1000 09/06/15): required oxygen via NRB to maintain saturations at ordered 92%. Short of breath when walking to BR. Lung sounds decreased in bases, cough weak and ineffective, and needed encouragement to use inspirometer to generate volumes of 500 mL and declined to walk greater than 4 times daily as ordered. Reluctant to take Norco. ADNS ASSESSMENT FLOWSHEETS: (1000 09/08/15) WDL = neurological, cardiac, abdominal, peripheral vascular, and skin. X= respiratory – RLL decreased breath sounds. I.S. to 2000 mL. Activity: x 3 650 feet in hallway with no shortness of breath. Requesting Norco two tablets every four hours, 3/0-10 abdomen aches, acceptable level is 4, satisfied with pain management. MAR: Norco 5/325 mg 1 – 2 tabs oral every 4 hours PRN pain – two tablets administered at 1400 today, Lovenox 40 mg subcutaneous daily (1800). ORDERS (today): Oxygen to maintain saturations greater than 92%; CBC in AM; Advance diet as tolerated; Discontinue LR at 75 mL/hr TEST RESULTS REVIEW: 9/4/15 U/A negative, 9/8/15 K+ 3.8, 9/8/15 Hgb 9.8, Plts 50,000, ASSESSMENT FLOWSHEETS (10:00 today, POD #4): WDL = neurological, respiratory, cardiac, abdominal, peripheral vascular, skin. WOUND: Staples intact, no drainage, no dressing, no redness. I/O: 100% full-liquid breakfast and lunch. Activity: 2x with standby assist 650 feet and maintained sats at 92% on RA. I.S. 1500 – 1750 10 times every one hour. CDB well and resting room air saturations are 94%. Pain: 3/0-10 pain, acceptable level of 4. PATIENT EDUCATION: Educated on diverticulitis and wound care.

I: Nancy Fairytale, a 35y.o female admitted on 9/4 with diverticulitis. S: POD 4 bowel resection. Pt ambulated BID SBA. Pain rating is at a 3 out of 0/10 scale. B: patient had a bowel resection 4 days ago due to diverticulitis. Incision site to midline. Tolerating liquids well. On 9/7 Hgb was 10.0, and on 9/8 it was 9.8, platelets are 50,000. A: Bowel sounds present. VS and I&O WNL. Has become more compliant with activity and use of IS. Pt is now able to maintain O2 sats. ABD would CDI with no s/s of infection. CBD well. R: recommend repeat labs and note possibility for iron and vitamin b12. Possible blood transfusion if patient consents.

SCENARIO 5: YOU ARE THE RN (YOU CALLED THE RAPID RESPONSE) GIVING REPORT TO THE NP AND CHARGE NURSE, WHOM HAVE RESPONDED TO THE RAPID RESPONSE IN THE NICU PATIENT SUMMARY: Jack Little, 3 week-old male, 27 weeks gestation. NICU PHYSICIAN NOTE (today): RESPIRATORY: Initiated C-PAP after birth. Short period of C-PAP discontinued and remains on oxygen at 4L/Min per NC, RR 30. I/0: 500 mL /350 mL over 24 hours, continuous tube feedings 15 mL/hr; Pedialite with steady weight gain. CARDIAC - heart monitor SR with rate of 130. Parents present and discussed plan of care with them. MAR: Tylenol 160 mg/5 mL oral every four hours PRN. ORDERS (today): Oxygen to keep saturations greater than 95%, discontinue C-PAP. Heart monitor, continuous Saturations, continuous tube feedings per dietician consult, daily weights NURSES NOTE (2200 yesterday): Tachypnea of 145, bradycardic episode (50 – 60s) with saturations decreased to 75% on 2L/Min per NC. With stimulation, HR returned to 130 and oxygen was increased to 4L/Min per NC, per protocol, saturations increased to 94%. Had small amount of regurgitation of formula. NURSES NOTE (1400 today): Today for the first time, he has had a couple of episodes of apnea. Muscle tone is diminished and his coloring is mottled. Respiratory rate is 48 and breath sounds equal and decreased. His abdomen is soft and not distended. He has slept a lot today and his mother feels he isn’t as alert as usual. ASSESSMENT FLOWSHEETS 1430: WDL = neurological, peripheral vascular. X = respiratory RR 75, cyanosis around mouth, using accessory muscle to breathe, 75% saturations on 4 L/Min per NC, X = cardiac HR 150, X = abdomen - spitting up formula. Rapid Response initiated. I: Jack, neonate born at 27 weeks gestation now 3 weeks old.

S: patient using accessory muscles when breathing and RR is 75 per minute, cyanotic around mouth and SpO2 at 75% on 4L via NC. Pt is tachy at 150 and experiencing periods of apnea. Patient has also been spitting up formula. B: when patient was born C-PAP was initiated and soon after discontinued and placed on 4LPM via NC. Yesterday patient had episodes of tachypnea 145, bradycardic (50-60s) with saturations decreasing to 75% on 2LPM via NC. Once O2 was increased to 4LPM HR returned to 130s, and saturations increased to 94%. Pt also experienced a small amount of regurgitation of formula. A: 30 min ago, pt had a couple episodes of apnea, RR was 48, breath sounds equal and decreased. Muscle tone was diminished, and his coloring was mottled. Mother felt pt was not alert as usual. R: C-PAP will probably be placed on the patient until saturations can get up to 95% again. Request Respiratory Therapy to assist with adequate placement. Hold feeding for prevent aspiration. Awaiting for further orders.

SCENARIO 6: PHYSICAL THERAPIST TO PATIENT’S PRIMARY HEALTH CARE PROVIDER’S NURSE CLINIC PHYSICIAN NOTE (4 days ago): Dennis Scott, 55 year-old male, seen in the clinic for low back pain. After cleaning his litter box, he was picking up a bag of cat litter when he experienced pain. He had immediate pain to the lower back and within an hour pain was radiating down the posterior aspect of the left leg and to the foot. Spine x-rays negative. +2 DTRs bilateral, + CMS, extremities warm, +3 dorsalis pedis pulses bilaterally. Physical therapy ordered and Ibuprofen for pain. Recheck in one week. No labs ordered. 140/80 98.6 69 20 94% room air saturations. History of Type II DM. PHYSICAL THERAPIST NOTE (2 days ago): He came to ordered P.T.; but, was unable to complete the full evaluation because of pain. He had no weakness on evaluation but his left ankle DTRs was slightly diminished. Both flexion and extension movements produced pain; however, flexion produced greater pain. PHYSICAL THERAPSIT NOTE (today): Today, he comes to his scheduled outpatient P.T. appointment with 9/0-10 left leg pain. When he is placed on a bike to try a warm up, he noticed that he didn’t feel the seat very well. He is a little hesitant to ride and distressed because last night he had an episode of bowel incontinence. He feels this happened because he has been “pushing so hard trying to urinate the last couple days, he just pushed too hard when he coughed.” He feels that if the bike makes him cough, it may happen again. The bike does not change his pain and he has no demonstrated weakness today. On further treatment, repeated movements did not improve his pain or symptoms. He continues to report numbness to his inner legs bilaterally and groin area. His left leg pain continues down posterior thigh and to the left foot. VS 98.6 88, 20

94% RA, 140/80. No recent labs. Home Medications: Ibuprofen 800 mg oral every 6 hours PRN pain - take once today Metformin 1000 mg oral twice daily – taken at 0800 Lisinopril 10 mg oral daily – taken at 0800 & Simvastatin 20 mg oral every HS – taken yesterday

SCENARIO 7: YOU ARE THE NURSE IN THE ED’S TRIAGE PREPARING TO GIVE REPORT TO NURSE IN ED PATIENT SUMMARY: Kim Unreal, 40 year-old female CHART REVIEW: Clinic Visit: 09/11/2015, Dr. Johnson, Internal Medicine, SBMC, yearly physical. History of Hepatitis C and hypothyroidism. Allergies to aspirin and sulfa drugs. ASSESSMENT FLOWSHEETS: WDL = neurological, respiratory, cardiac, peripheral vascular, skin. X = abdominal URQ liver enlargement, nausea, vomited twice prior to arriving and states vomit had bright red blood in it. VS 102.5 80 20 96% RA 120/80. X = psychosocial – very worried about “some kind of liver disease I have.” HOME MEDICATIONS: Ibuprofen 800 mg three times daily for abdominal pain – taken 2 doses today Synthroid 0.25 PO Daily – taken today Calcium/Vit D 600 mg PO twice daily – unsure when last taken TEST RESULTS REVIEW: Per triage protocol, BMP, LFTs, and CBC done with results pending. IHi ED nurse, I bring you Kim Unreal, a 40 year old female. S-

Patient came in today to the ED triage c/o nausea, vomited twice before arriving. Patient stated that vomit had bright red blood

in it. B-

Patient has an allergy to Aspirin and Sulfa drugs. Pt had a Clinic visit on 9/11/15 with Dr. Johnson in internal medicine, SBMC,

and yearly physical. Past medical history of Hep C and hypothyroidism. Patient took her Syntroid 0.25mg today and calcium/Vit D is unsure when she last took. Ibuprofen is scheduled 800mg TID for abdominal pain- she had taken two doses. A-

Patient stated she vomited twice prior to arriving and the vomit had bright red blood. Upon assessing the RUQ liver was enlarged. Patient stated she was worried about “some kind of liver disease she had”. Patient is having a Hepatitis flare up. VS 102.5

80 20 96% RA 120/80. R- I would recommend waiting on labs to confirm Hep C flare up. Place an PIV as most likely they will order IV medications.

SCENARIO 8: YOU ARE THE RN AT CLINIC AND PREPARING REPORT FOR PATIENT’S NP AT CLINIC PATIENT SUMMARY: Margaret Madeup, 68 year-old female, reporting severe pain in both ears. She is extremely hard of hearing. She does not wear hearing aids. ASSESSMENTS (1300): 100.2 85 16 94% RA 110/64. Took Tylenol at home about two hours ago. Pain: 6/0-10 both ears with limited relief from ear drops or Tylenol. Rubbing ears. CHART REVIEW: Clinic Visit 09/01/15: Kathy White, RN,CNP, SBMC, for severe pain in both ears. WBC 12. History of gout, HTN, depression. HOME MEDICATIONS: Erythromycin 500 mg oral four times daily for ten days – taken twice today Lisinopril 20 mg oral daily for HTN – taken today Zyprexa 10 mg oral daily for depression – taken today Zyloprin 600 mg oral daily for gout – taken today

I: Margaret Madeup, 68y.o female S: pt came in today reporting severe pain in both ears. B: patient is extremely HOH and does not wear hearing aids, has a hx of gout, HTN and depression. Pt had a previous clinic visit on 9/01 with Kathy White, RN, CNP, SBMC, for severe pain in both ears. At the time patient had a WBC of 12. Currently taking Erythromycin 500mg oral QID for 10days; has taken it twice. Lisinopril 20mg oral daily, Zyprexa 10mg daily, and Zyloprin 600mg daily; all taken today. A: Temp was 100.2, HR 85, RR 16, 94% on RA, BP of 110/64. Took Tylenol two hours ago; and is currently rating her pain at a 6/0-10 on both ears. R: recommend repeating labs. Assessing the ear with a otoscope. Possible to change antibiotic and more pain medication meanwhile.

SCENARIO 9: YOU ARE THE RN PREPARING REPORT TO THE HOSPITALIST RESPONDING TO CODE PATIENT SUMMARY: Judy Notrue, 60 year-old female, diagnosis CP Possible MI ADULT ADMISSION (to ICU 45 minutes ago): History: CAD, CVA. No allergies. VS 99.0 90 20 94% on 2L/Min 160/82. Direct admit via ambulance from Cass Lake Hospital. Elevated cardiac enzymes at Cass Lake. EKG at Cass Lake had elevated T waves, HR 110. Three baby Aspirin given in Cass Lake ED. Patient’s perception of illness: Haven’t felt well for one week, lots of nausea and indigestion. MAR: Cardizem 240 mg oral daily – took one today, Coreg 6.25 mg Oral twice daily – took one today Aspirin 81 mg oral daily – forgot to take today ORDERS ON ADMISSION: EKG and CXR – done, Oxygen to keep saturations greater than 92% - ambulance started this Activity as tolerated, saline lock, STAT LABS: MI Profile, CBC, BMP - drawn Cardiology consult and schedule stress test – not done yet, Echocardiogram – done ASSESSMENT FLOWSHEETS: WDL = neurological, respiratory, abdominal, peripheral vascular, skin. X = cardiac S3, tachycardia, 160/82, COMMENT – very nauseated and has indigestion TEST RESULTS REVIEW: Cardiac enzymes elevated, BNP 4,000, K+ 3.9, Mag 1.4, Na 129, WBC 12,200, Hgb 15, Hct 45, Plt 350,000,; U/A neg EKG indicating ST elevation Echocardiogram indicating atrial stenosis and regurgitation CXR shows atelectasis Echocardiogram shows HF Now: Suddenly puts on call light and is found pulseless, cyanotic, no RR. Code Blue initiated.

SCENARIO 10: YOU ARE THE RN PREPARING REPORT TO CHARGE NURSE ON UNIT PATIENT PROFILE: Kathy Makebelieve, 25 year-old female, direct admit at this time from Altru Clinic to Altru Hospital medical-surgical unit with diagnosis of severe abdominal pain possible cholelithiasis

ADULT ADMISSION HISTORY (1230): History of gallstones, five months pregnant with third baby. VS 103.5 98 22 98% RA,190/84. T 99.9 at clinic. She has been receiving prenatal care. HOME MEDICATIONS: Prenatal Vitamin 1 tab oral daily – taken today ASSESSMENT FLOWSHEETS: WDL = neurological, respiratory, cardiac, abdominal, peripheral vascular. X = Pain: 8/0-10 RUQ burns, sharp, had since 0400 today, getting worse. ORDERS: Surgery consult, NPO CXR OB consult CBC, BMP, U/C Ultra sound of gall bladder NS at 150 mL/hr Tylenol 650 mg oral every 6 hours PRN fever/pain – given 1300 Dilaudid 1-2 mg IV push every one hour PRN pain – 1 mg given 1300 TEST RESULTS REVIEW: CBC and BMP pending, U/A slight protein I: Kathy Makebelieve, 25y.o female direct admit from Altrus clinic for severe abdominal pain possible cholelithiasis. S: Patient has just been admitted for severe abdominal pain that has been worse since 0400 today; possibility of cholelithiasis, she is 5mo pregnant with third baby. B: previous medical history of gallstones. Currently on prenatal care. Taking a prenatal vitamins; taken today. A: VS 103.5 98 22 98% RA 190/84 T99.9 pain at 8/0-10 scale in the RUQ, burns sharp R: patient receive pain medications, PIV placement and start NS at 150mL/hr. CXR pending, ultrasound pending, surgery consult pending.

SELF-REFLECTIVE QUESTIONS 1. Describe a situation at clinicals, during simulation,...