SBAR Case Study - homework PDF

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SBAR Case Study: Problem Based Case Study Guidelines for Communicating with Physicians Using the SBAR Process When calling the physician, follow the SBAR process:

(S) Situation: What is the situation you are calling about (it's ok to make some of this up)?  

Identify self, unit, patient, room number. Briefly state the problem, what is it, when it happened or started, and how severe.

(B) Background: Pertinent background information related to the situation could include the following:    

 

The admitting diagnosis and date of admission List of current medications, allergies, IV fluids, and labs 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

(A) Assessment: What is the nurse’s assessment of the situation? (R) Recommendation: What is the nurse’s recommendation or what does he/she want? Examples:   

Notification that patient has been admitted Patient needs to be seen now Order change

(CE) Clinical Evidence:  

When analyzing the signs and symptoms, what could be causing the change in the patient’s condition? What is the clinical evidence to validate the recommendation? You must provide references here.

A 21-year-old male was admitted to the emergency department of a hospital in complaining of nausea/vomiting, abdominal pain, and periumbilical pain. Computed tomography of the abdomen/pelvis revealed ileal thickening and a small bowel obstruction. The differential diagnosis was infectious enteritis versus Crohn’s disease. The patient was admitted to the hospital and treated with nasogastric suction, intravenous fluids, and antibiotics. He subsequently complained of recurrent abdominal pain, new-onset diarrhea, and rectal bleeding. A colonoscopy demonstrated ulcerations of the ileum and colon consistent with Crohn’s disease; the ileum was notably stenotic, and only the distal few centimeters could be visualized. A small bowel follow-through study with barium contrast showed the stenoses and ulcerations extending over the distal 30 cm of the ileum and confirmed a diagnosis of Crohn’s disease. Treatment with mesalamine 4 g/day and a 14-day course of metronidazole relieved the abdominal pain and bleeding, but the diarrhea persisted.

The patient alerted the nurse of new onset epigastric pain 10/10 with radiation to back and nausea/vomiting preventing any oral intake. Vital signs are as follows: T- 99.4; BP 160/70; HRR 110; RR - 22...