SBAR S.D 52 - SBAR For Sheila Dalton PDF

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Summary

SBAR For Sheila Dalton...

Description

SBAR Template Situation: Name/age: Sheila Dalton, 52 years old Female.

BRIEF summary of primary problem: Patient states pain as 6/10 as a result of being 1-day post op from a posterior spinal fusion of L4-S1.

Day of admission/post-op #: Transfer patient from the PACU 1-day post operation.

Background: Primary problem/diagnosis: Current pain of 6/10 after posterior spinal fusion of L4-S1 surgery.

RELEVANT past medical history: • • • • • •

history of chronic low back pain and COPD Low back pain with lumbar compression fracture Depression COPD Hypertension 2 packs per day smoker x 32 years

RELEVANT background data: Patient is divorced and currently lives alone. Patient has two grown children from whom she is estranged.

Assessment:

Current vital signs: T: 100.2 F/37.9 C (oral) P: 110 (regular) R: 24 BP: 98/50 O2 sat: 88% 4 liters per n/c

RELEVANT body system nursing assessment data: The patient appears uncomfortable, her is body tense, frequent grimacing and she last used PCA 10 minutes ago.

RELEVANT lab values:

Normal lab values:

WBC 11.8

(4.5–11.0 mm 3)

Hgb 10.4

(12–16 g/dL)

Neutrophil 85%

% (42–72)

Brand forms 1%

(3–5%)

Sodium 134

(135–145 mEq/L)

Glucose 148

(70–110 mg/dL)

TREND of any abnormal clinical data (stable/increasing/decreasing): WBC 11.8

Improving

Hgb 10.4

Worsening

Neutrophil 85%

Improving

Brand forms 1%

Stable

How have you advanced the plan of care? I have increased her oxygen to help with her low O2 Sat. Patient response:

Patient states pain of 6/10 from having a pain of 2/10 when transferred from PACU.

INTERPRETATION of current clinical status (stable/unstable/worsening): Patient may be developing an infection AEB abnormal lab values.

Recommendation: Suggestions to advance plan of care:

• • •

Reinforce the use of Incentive spirometer to prevent pneumonia and reduce fever. Remove Foley catheter to prevent UTI. Notify her physician if her BP continues to drop and her HR starts to increase.

© 2016 Keith Rischer/www.KeithRN.com...