SBAR linda waterfall VSIM PDF

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SBAR documentation for linda waterfall VSIM...

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Jessica Carey Professor Rodriguez NUR 136 – 34407

SBAR – Linda Waterfall

Situation: The patient is Linda Waterfall, a 48-year-old female who is scheduled for a left mastectomy this morning at 8:30 a.m. The patient is having second thoughts about having surgery due to not having her medicine bundle. In the patient’s culture it is important to have her medicine bundle with any medical procedure to promote good health. The patient states that she was in a rush this morning and anxious and must have left the medicine bundle at home. The patient’s cousin Alice is in the room with her for support. The patient seems anxious and uncertain about surgery. Background: The patient was admitted to the hospital for a left breast mastectomy this morning. A biopsy done only a few days prior revealed aggressive cancer in the left breast. The patient has not had any contact with her family members who live far away. The patient’s family members wanted the patient to return home to heal with their tribal healers, but the patient refused. The patient took the first available appointment for surgery. The patient shared her mother died from complications due to surgery. Assessment: I assessed the patient and she has difficulty concentrating second to anxiety. She is worried about the cancer and expresses difficulty is accepting losing her breast. The patient is restless, speech is fluid, normoactive and appropriate volume. The patient denies pain. She complains of difficulty breathing and denies chest pain. The patient shares having a hard time sleeping when feeling anxious. IV is intact. V/S: 24 RR, SpO2 100%, BP 150/80 mmHg, Temp. 37 Degrees C (98.6 degrees F), HR 110 regular without murmurs. The patient has had no changes in weight and skin is normal temp. and normal color and not sweating. I educated the patient about her rights and decisions regarding surgery. The

patient replied “I don’t want anyone to be upset with me. I know I have taken up a lot of your time and the doctor’s time. But I can’t do this without my medicine bundle”. I did some deep breathing with the patient to calm her anxiety. Recommendation: I recommend teaching deep breathing exercises and relaxation techniques to help the patient with her anxiety. I suggest that you consult with the patient to reschedule surgery after techniques have been taught to lessen her anxiety and worries and until her medicine bundle has been located. I suggest that you educate the patient on the risks and benefits of surgery. I also recommend the patient talks to either a psychiatrist or the family’s tribal healer to express her concerns about surgery....