SBAR Examples & Case Studies PDF

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SBAR Examples & Case Studies...

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Example of SBAR Case Study Scenario: Mrs. Ghuman is a 56-year-old woman who was diagnosed with heart failure 4 years ago. She has been admitted to the hospital for shortness of breath (SOB). She states “I was taking a diuretic at home but ran out 2 days ago. 1 have not been able to refill my prescription”. She complains of difficulty breathing and has noticed some swelling in her feet that seemed worse than usual. On physical examination, you observe that she is alert and oriented to person, place, and time. For respiratory assessment, she has SOB on exertion; oxygen saturation is 89% on room air. On auscultation, you hear fine crackles bilateral in the lower lobes. When assessing her lower extremities, you fine 2+ edema bilaterally. Vital signs are: T- 37.0, BP – 130/85, P – 120, R35/min. Next Step: SBAR State to the student: “You find that you want further guidance in what should be done next with your client. You decide to call the Registered Nurse in the unit next to yours, and consult with them on the situation. What do you tell them? SITUATION - Hi my name is ________________ , I’m calling from the General Medicine Unit. - I’m calling about Mrs. Ghuman admitted to bed __________________ - She is showing signs and symptoms consistent with Heart Failure. BACKGROUND - she is a 56 year old women who was diagnosed with heart failure 4yrs ago - she has been managing her condition at home but has not been taking her diuretic for the last two days and has noticed increased edema in her feet, and SOB - initial vital signs are T- 37.0, BP – 130/85, P – 120, R- 35/min, 02 89% on RA - Also, fine crackles on auscultation and 2+ edema on lower extremity - So far, I have ........(interventions) ASSESSMENT What is your assessment of the situation? Provide details of any changes in patient status that support your assessment, such as: (X) mental status ( X) Resp rate/quality ( X) Pulse/BP changes

( ) Neuro changes (i.e. weakness, speech) (X ) Retractions/Use of accessory muscles ( X) Peripheral pulses/Edema

RECOMMENDATIONS

( ) Pain (X ) Skin Colour ( X) Adventitious sounds

What are your Recommendations? Do you think we should: (State what

you would like to see done) (X) Have an available Doctor come and see the patient? (X) Have any tests done like: (X) CXR (X) ABG (X) EKG (X) CBC ( ) others? If a change in treatment is ordered, then ask: (X) How often do you want vital signs/other assessments completed? (X) If the patient does not improve, when would you want us to call you again?

Case Study #1

Scenario: Mrs. Singh is an 80 year old female with a Left Cerebrovascular Accident (CVA) who has been in a long term care facility for the past10 years. She is immobile and has to be transferred with the mechanical lift. Her nutritional needs are met with 6 cans of Isosource via G tube @ 50 mls /hour. You are assigned to Mrs. Singh on the evening shift and you provided hygiene care and repositioned her. Mrs Singh's routine medications were administered at 1800hr. Her G feed (1 can Isosource) is also in progress. At 2000hr, when you approach Mrs Singh's bed, you hear her coughing, respirations are noisy and her face is flushed. Her vital signs are T39, 110 bpm, R 32 /min, BP 150/90 and SP02-86% on room air. SITUATION - Hi my name is ________________ , I’m calling from _________________ - I’m calling about __________________ BACKGROUND -

ASSESSMENT What is your assessment of the situation? Provide details of any changes in patient status that support your assessment, such as: ( ) mental status ( ) Resp rate/quality ( ) Pulse/BP changes

( ) Neuro changes (i.e. weakness, speech) ( ) Retractions/Use of accessory muscles ( ) Peripheral pulses/Edema

( ) Pain ( ) Skin Colour ( ) Adventitious sounds

RECOMMENDATIONS What are your Recommendations? Do you think we should: (State what you would like to see done) ( ) Have an available Doctor come and see the patient? ( ) Have any tests done like: (X) CXR (X) ABG (X) EKG (X) CBC ( ) others? If a change in treatment is ordered, then ask: ( ) How often do you want vital signs/other assessments completed? ( ) If the patient does not improve, when would you want us to call you again?

Case Study #2

Scenario: You are completing an initial assessment on Mr. Edwards, a 62 year old male with a history of headaches who visits the local medical clinic. You find that Mr. Edward's vital signs are stable, his eyes open spontaneously and his bilateral hand and leg strength are normal and equal. He is oriented times 3 and he states that his current pain is 6/10. When asked about how long he has been having the headache, he states "it has been off and on for several months". He states that sometimes he experiences some nausea, with no vomiting. On PERRLA assessment the RPN notices that his right eye is 3+, whereas his left is 5 and non reactive. As you carry on with the assessment, Mr. Edwards appears to be staring at the wall and all of a sudden his legs and arms begin to jerk. He is nonresponsive during this episode; you recognize this to be a clonic tonic seizure. The seizure lasts 45 seconds. Vital signs at this time are: T- 36.5 9Sbpm R -26/min 02 saturation 95 % on room air. BIP 130/80 SITUATION - Hi my name is ________________ , I’m calling from _________________ - I’m calling about __________________ BACKGROUND -

ASSESSMENT What is your assessment of the situation? Provide details of any changes in patient status that support your assessment, such as: ( ) mental status ( ) Resp rate/quality ( ) Pulse/BP changes

( ) Neuro changes (i.e. weakness, speech) ( ) Retractions/Use of accessory muscles ( ) Peripheral pulses/Edema

( ) Pain ( ) Skin Colour ( ) Adventitious sounds

RECOMMENDATIONS What are your Recommendations? Do you think we should: (State what you would like to see done) ( ) Have an available Doctor come and see the patient? ( ) Have any tests done like: (X) CXR (X) ABG (X) EKG (X) CBC ( ) others? If a change in treatment is ordered, then ask: ( ) How often do you want vital signs/other assessments completed? ( ) If the patient does not improve, when would you want us to call you again?

Case Study #3 Scenario: Miss Lucy Smith, a 28 year old female was admitted to your unit (Medicine 4 H) on the previous night shift for abdominal pain not yet diagnosed (NYD). The shift report stated that vitals were stable on admission. Upon shift change, you enter her room and she was moaning loudly and complaining of severe abdominal pain. She has just returned to bed after going to the washroom. When you looked in the toilet, you noticed that she has had a large, bloody loose stool. She states that she has had "at least one like that each day for the past week." She states "I feel so tired and unwell. 1have never felt this bad before, 1can hardly stand long enough to brush my teeth"! Her colour is pale, skin cool and diaphoretic. She is alert, knows her name, the date, and where she, but she is very fatigued. Vital signs at 0800 hrs are: T-36.5, 55bpm, 18R1min, BP 105/55 and 02 saturation 97 % on room air. SITUATION - Hi my name is ________________ , I’m calling from _________________ - I’m calling about __________________ BACKGROUND -

ASSESSMENT What is your assessment of the situation? Provide details of any changes in patient status that support your assessment, such as: ( ) mental status ( ) Resp rate/quality ( ) Pulse/BP changes

( ) Neuro changes (i.e. weakness, speech) ( ) Retractions/Use of accessory muscles ( ) Peripheral pulses/Edema

( ) Pain ( ) Skin Colour ( ) Adventitious sounds

RECOMMENDATIONS What are your Recommendations? Do you think we should: (State what you would like to see done) ( ) Have an available Doctor come and see the patient? ( ) Have any tests done like: (X) CXR (X) ABG (X) EKG (X) CBC ( ) others? If a change in treatment is ordered, then ask: ( ) How often do you want vital signs/other assessments completed? ( ) If the patient does not improve, when would you want us to call you again?...