SBAR Template

SBAR Template  

                                              SBAR Assessment

Situation:

“What is going on with this patient?”

 Chief Complaint (what symptoms the patient came to the hospital with):

Patient was involved in MVA going 45 mph and hit a tree.

Diagnosis_Right Ankle Fracture           Vital Signs: BP-108/71 P-76 Temp- 98.7 F; O2 Sat 99%      

Pain Level___6_________  Where_Rt leg, chest, & rt wrist_______________

Description_Acute, somatic, pain in rt leg, thorax, and rt wrist SBAR Template

 

Allergies_NKA_

Primary MD__Gannu_____________             Code Status (DNR?)  N/A (Full code)

ORDER A PLAGIARISM-FREE PAPER HERE

Weight_76.2___kgs                                          Isolation_____N/A______________

Date of admission__10/6/18____________
Background

“What is the clinical

Background?”

 PMH (Previous medical history including past surgeries)

Diabetes Mellitus, Smoker, Bipolar, Mood Swings, Depression, Heroin Use
Assessment

 

“Head-to-toe assessment that I am going to chart into the EMR after I review it with my instructor organized by body system.”

 
Respiratory (Resp)

Respiration Rate ______16___________   Lung Sounds_____Clear_____________

Supplemental Oxygen __N/A_______LPM   Oxygen Saturations__99%___________

 

Incentive Spirometry __unknown (I will check EMR next time & collaborate with Respiratory Therapist)
Cardiovascular (CV)

 

Heart Rate:  Regular______________

 

IVF’s __ Saline Lock__________Rate_ N/A _____________

 

IV Site_Left mid forearm______________ Start Date_10/6/18_________

 

Edema (where/rate): rt wrist +1; rt lower limb (unable to assess due to ace bandage & splint)

Pedal Pulses: Strong on left foot, unable to assess rt foot due to ace bandage & splint

 
Neurovascular (Neuro)

Alert and Oriented X4________ or

Altered mental status___ N/A______                       Deficits__ N/A_______

 
Gastrointestinal (GI)

Diet   Normal______      Last Bowel Movement___10/8/18_________

 

Assistance eating __no_______   Bowel Sounds__Present x 4_______________

 

Any Drains present____ N/A________         Accuchecks ___90_________________
Genitourinary (GU)

Voiding__Yes__________                     Foley Catheter__ N/A_______

 

Description Of Urine unknown___________________________________________

____________________________________________________________________

I and O’s

Input ____ N/A_______         Output___ N/A________

 
Musculoskeletal

Activity _Limited__________                    Falls Risk Score_70______  Falls Risk  Y

SCD’s____ N/A________

Assistive Devices _Walker______________

ROM _Non-weight bearing right leg, limited ROM
Special Concern’s/Problems/ Scheduled events for the day

Any wounds/ Skin Breakdown Present

Location _Rt lower limb__ Dressing type Ace bandage; unknown dressing type     underneath__

Presence of drainage from wound or on dressing (describe drainage characteristics)

Unknown due to splint and ace bandage on right lower limb. No visible drainage through the ace bandage. Ace Bandage is dry and intact.

Any diagnostic tests or procedures scheduled for today? No. SBAR Template

10/6/18 -Head CT: No evidence of intercranial hemorrhage or acute findings within the brain.

10/6/18-XR(Pelvic, Rt Knee, Rt Tib/Fib, Chest) Comminuted fracture of the distal fibula & medial malleolus w/o displacement. Bilateral fracture of the first ribs.

Abnormal Labs from 10/9/18- Hematology: WBC 12.4 (H)(normal 4-11); monocytes 10.7%(H)(Normal 2-8%);Neutrophils# 8.2(H)(normal 1.5-8);monocyte # 1.3(H) (Normal 0.2-1.0) Chemistry: Na 132(L) (normal 135-145);BUN/Crea Ratio 21.0 (H) (normal 10-20)

Physical Therapy_Yes, educated pt on how to ambulate w/o using NWB right leg____
Recommendation

(Evaluation)

What do you think should be done to help your patient

This is a summary of your shift’s observations that could assist the next shift in planning  care for the patient

  

Discharge Plan

·         Rest. Limit patient mobility, until right leg can bear weight. Eventual use of CAM boot when ambulating.

·         Place an ice pack on right lower limb in 20 minute increments 6-8 times/day

·         Elevate leg on pillows to help with swelling.

·         Compression. Continue with ACE bandage and splint on right leg for support and to ease swelling.

·         Continue with incentive spirometer 5-10 times every 2 hours. SBAR Template

·         Have patient wiggle toes on right foot often to promote blood flow.

·         Continue with physical therapy to learn how to safely ambulate using walker/crutches due to NWB status of right leg.

·         ROM exercises for unaffected joints of the body.

·         Consult with Social Services and Case Manager. Possible transfer to skilled nursing facility for rehab due to patient’s living situation SBAR Template.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUR 133 SBAR/Physical Assessment Tool Rubric-

  

Student Name:

 

 

Date:

 

Section Satisfactory Needs

Improvement

 Unsatisfactory Comments
Basic Information All areas addressed Some areas addressed None of the areas addressed  
Neurologic All areas addressed Some areas addressed None of the areas addressed SBAR Template
Skin All areas addressed Some areas addressed None of the areas addressed  
Head, Eyes, Nose, Throat All areas addressed Some areas addressed None of the areas addressed  
Respiratory All areas addressed Some areas addressed None of the areas addressed  
Cardiovascular All areas addressed Some areas addressed None of the areas addressed  
Gastrointestinal All areas addressed Some areas addressed None of the areas addressed  
Genitourinary All areas addressed Some areas addressed None of the areas addressed  
Musculoskeletal All areas addressed Some areas addressed None of the areas addressed  
Psychosocial All areas addressed Some areas addressed None of the areas addressed SBAR Template