NR 305 Week 8 Discussion Topic: Rapid Assessment of a Client

SBAR Report: Rapid Assessment of a Client – Please choose one of the patient scenarios below. Next, complete a rapid assessment, and provide a SBAR report to a classmate. Remember to include all concepts of patient safety, standard precautions, and professional standards.

• You are in the process of admitting Ashley, a 27 year old who is 28 weeks pregnant with her first child, to the obstetric unit for complaints of headache, dizziness, and swelling of her lower extremities when she suddenly begins seizing.

Part 1 of the Assignment – Communication

Section A – Questions (3 points)

• Answer the following three (3) questions in question and answer format
• APA format is NOT required; short form expression is permitted as is the use of bullets to answer the three questions. Please note that the form of writing expression the learner selects must be understandable to the reader.

 

Define and describe the SBAR Tool, answering the following questions:

1. What does SBAR stand for?
2. What is the purpose of the SBAR tool?
3. When should a SBAR tool be used?

Section B – Case Scenario Analysis using SBAR (15 points)

• For the Case Scenario Analysis using SBAR, ONLY a chart with columns may be used to answer the questions. DO NOT answer in paragraph format. An example of how to set up a chart (you may use as many columns and/or rows as you wish and label accordingly):

		Major Issues	Missing Information	Nursing Actions Taken

 

1. Based on the following Case Scenario, complete a comprehensive end of shift hand off report using the SBAR format. In your report include:
2. The major issues of the case scenario
3. The information missing from the case scenario
4. As the nurse taking care of the patient, what actions did you take? Include this information in the appropriate section of the SBAR for your Handoff Report.
5. You may need to “make up” some information to complete the chart and answer these questions.

 

******Case Scenario – Patient Profile******

You have been working a 12 hour day shift providing care for Ms. P, a 23 year old female who has Down Syndrome. She had an emergency appendectomy yesterday. You will give the Handoff Report to the nurse working a 12 hour night shift (for this assignment your handoff report will be given to the Instructor).

Subjective Data

• Ms. P’s parents are at the bedside and tell you Ms. P is increasingly restless and pulls at her surgical dressing
• The parents also tell you Ms. P declined her dinner as she vomited greenish fluid

Objective Data

• Vital signs: T – 37.7 °C, P – 80, R – 20, BP – 110/78, pulse oximetry – 98 %
• Surgical dressing is clean, dry and intact, bowel sounds are hypoactive
• Morphine sulfate 8 mg IVPB (IV piggy back) was given at noon
• At 1800 when Ms. P declined her dinner due to emesis of green fluid, you gave her Metoclopramide 10 mg IVPB • Intake: Oral = 100 IV = 900 IVPB = 100
• Output: 400

Collaborative Care

• IV D5/0.9 NS 1000 ml infusing at 125 ml/hr into left forearm (LFA) #20 g with 200 ml left in the bag
• Medications o Cefoxitin 1 Gm IVPB Q8H o Metoclopramide 10 mg IVPB Q6H PRN for nausea and vomiting o Morphine sulfate 8 mg IVPB Q4H PRN for pain
• V/S Q4H
• Clear liquid diet
• Ambulate with assistance