Time Plan and SBAR Template document 3 (week 11) PDF

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Summary

VSIM labs that require an SBAR & Time plan...

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VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY

SBAR Instructions: Imagine you took care of __Skylar Hanson____(VSIM Scenario Patient) on clinical day one and you are at the end of your shift. You are required to provide verbal report to the next nurse who is assuming responsibility of ________(VIM Scenario Patient). Based on your VSIM experience specific to this ____________(VSIM Scenario Patient), how would you formulate a change of shift report in a SBAR format. After you formulate the SBAR, you are required to present this TOA with the rest of the clinical group in the virtual meeting.

SBAR Presentation Situation: 18-year-old male admitted to the Emergency Department by his friends. PT experienced a hypoglycemic crisis and lost consciousness after his blood sugar reached 39 mg/dL Dx: Diabetes Background:

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PT was diagnosed with type 1 diabetes 6 months ago.

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The friends report that he started acting “weird” while they were playing basketball. He has not eaten anything for 5 hours.

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Skyler told them that he felt lightheaded and was going to lie down on the cement. They became nervous and decided to bring him in to the Emergency Department.

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PT was drowsy, wakes with stimulus, had slurred speech, was diaphoretic, and was acting irrationally.

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Medications ordered were 50 mL of dextrose 50% in water IV slow push. IV is located in right hand. (Administered at 1540)

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O2 to be greater than 92% (6L via NP was given to PT)

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Venous Blood sample was taken.

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Carbs and protein were given.

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Vital signs to be monitored every 5 minutes & BG to be monitored PRN.

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No known allergies

Assessment:

Current PT status: -

ECG: Sinus rhythm.

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Heart rate: 81.

VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY

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Pulse: Present.

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Blood pressure: 123/73 mm Hg.

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Respiration: 12.

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Conscious state: Orientated x3

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SpO2: 98%.

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Temp: 99 F (37 C)

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There is normal skin turgor. His color is normal, and he is not sweating.

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IV site: No signs of pain or discomfort.

Recommendation:

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Place patient in a semi-high fowlers position to promote breathing.

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Continue to educate PT on his medical condition (diabetes) and the effects of hypoglycemia.

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Monitor vital signs and any significant changes in BG. Inform provider if there are any abnormalities.

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Monitor PT LOC and Orientation.

TIM PLAN/INTERVENTIONS (STUDENT EVALUATIONS/ASSESSMENT TO COMPLETE THIS SECTION S E ONLY) 150 0

Arrive to unit early to go over PT charts and get prepared for the shift. Meet w/ clinical instructor to obtain info about: primary nurse, primary patient, and objectives of the day.

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY*

153 0

Begin the shift, visit Skylar first. Hand hygiene Introduce self Identify PT Clarify allergies Verify consent

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

153 5

Collect any changes about client condition from Kardex, PT chart, change of shift report, medication from MAR.

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY

154 0

Perform hand hygiene, Assess neurological. Vital signs assessment (BP, PR, T, RR, PPR) General Survey Head to Toe assessment (inspect head for airway clearance)

155 0

Call provider/ask instructor to call provider because something is happening to the PT. (hypoglycemic crisis and lost consciousness)

155 5 160 5

Place NP on at 6L

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

Take BG.

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

161 0 161 5

Attach 3 lead ECG.

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

Obtain access to IV area and begin preparing medication with instructor.

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

162 0 162 5 163 0 163 5 164 0 165 0 170 5 171 0 171 5

Don gloves and admin IV medications w/ instructor supervision

172 5 173 5 174 0

Have them teach back to ensure that they understand the importance.

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

Review new orders.

Doff gloves and document medication

Check BG

Position PT in high fowlers, offer Carbs and Protein.

Assess Vital Signs.

Inform primary nurse about a 15 min break

Return to unit and inform primary nurse.

Reassess PT LOC, Vital sign, and BG.

Educate primary client on diabetes and hypoglycemia. Document progress notes about Client ADL’s, nursing care, and health teaching w/ clinical instructor

Don gloves and assess IV site.

Don gloves and take a Venous Blood sample.

VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY

121 5 123 0

Inform Primary nurse that you will be taking a break and heading to post conference w/ clinical instructor. Inform PN of the PT care that has taken place. Attend post conference.

SBAR Presentation Situation: 26-year-old female police officer with paraplegia from a thoracic 8 (T8) spinal cord injury. She was transferred to the Rehabilitation unit yesterday.

Background:

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Spinal cord injury was caused by a low-velocity gunshot wound to her back at the T8 level while she was responding to a robbery 8 days ago.

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The bullet penetrated the spinal column with no injury to visceral organs.

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Last bowel movement was yesterday at 1900.

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The gunshot wound appears healed.

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There is no movement or sensation to the lower extremities.

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She has been out of bed to a wheelchair.

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Regular, high-fiber diet.

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Medications ordered: Omeprazole 40 mg orally daily (0900), Enoxaparin sodium 40 mg subcutaneously (0900), Oxybutynin 5mg ex. Release orally (0900), Docusate sodium 100 mg orally every night.

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No known allergies

VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY

- IM cath every 4 hours. Assessment: -

ECG: Sinus rhythm.

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Heart rate: 90.

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Pulse: Present.

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Blood pressure: 126/83 mm Hg.

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Respiration: 19.

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Conscious state: Appropriate.

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SpO2: 96%.

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Temp: 98 F (36.8 C)

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PT cannot move her legs. There is no sensation for temperature, noxious or tactile stimulus. Reflexes are absent in both legs. There is normal elasticity of the skin. Her color is normal, and she is not sweating.

Recommendation:

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Perform bladder scan prior to IM cath, change every 4 hours.

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Continue to educate PT on bladder management program, safety, positioning, and input/output.

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Monitor input and output, the volume should be under 500 mL to prevent overdistention of the bladder.

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Provide teaching and training on clean technique for intermittent catheterization.

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Monitor vital signs and skin, encourage use of stockings.

Your TIME PLAN Must be presented to the clinical group on VSIM day. For reference a sample Time Plan is posted on ecentennial under week 7 contents.

TIM PLAN/INTERVENTIONS (STUDENT EVALUATIONS/ASSESSMENT TO COMPLETE THIS SECTION S E ONLY) 073 0

Arrive to unit early to go over PT charts and get prepared for the shift. Meet w/ clinical instructor to obtain info about:

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY*

VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY

primary nurse, primary patient, and objectives of the day.

074 0

Begin the shift, visit Kim Johnson first. Hand hygiene -

Introduce self

-

Identify PT Clarify allergies

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

074 5

Collect any changes about client condition from Kardex, PT chart, change of shift report, medication from MAR.

075 0

Perform hand hygiene, Assess neurological.

082 0 083 0 084 0 084 5 085 0 090 0 091 5 092 5 100 0 101 5 103 0 104 5 110 0 111

Don gloves and perform bladder scan, remove gloves, and document accordingly.

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

Don gloves to prep IM cath.

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

Begin IM cath change, discard of cath. Follow appropriate hand hygiene.

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

Assist w/ morning care

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

Set up for breakfast

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

-

THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY

Vital signs assessment (BP, PR, T, RR, PPR) General Survey Head to Toe assessment (inspect legs) Pain assessment.

Prepare medications w/ instructor. Admin medications w/ instructor supervision. Document medications accordingly.

Assist primary nurse w/ other patients

Meet primary client and reassess for S/S and any pain.

Inform primary nurse about a 15 min break

Return to unit and inform primary nurse

Meet with primary client to educate them on bladder management program, safety, input and output, and medications. Meet with clinical instructor to discuss nursing interventions to help alleviate any PT discomfort or issues. Reiterate PT education and perform nursing interventions.

VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY

5 113 0 114 5 120 0 121 5 123 0

Re-educate PT on prior teaching topics, have them teach back to ensure that they understand the importance. Document progress notes about Client ADL’s, nursing care, and health teaching w/ clinical instructor. Inform Primary nurse that you will be taking a break and heading to post conference w/ clinical instructor. Inform PN of the PT care that has taken place. Come back from break and prep for post conference.

Attend post conference....