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)
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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
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