Include this information in the appropriate section of the SBAR for your Handoff
ID: 124994 • Letter: I
Question
Include this
information in the appropriate section of the SBAR for your Handoff Report.
******Case Scenario******
Patient Profile
You have been working a 12 hour day shift providing care for Mrs. L, a 42 year old female who is one day post op total abdominal hysterectomy. You will give the Handoff Report to the nurse working a 12 hour night shift.
The following is information from your shift:
Subjective Data
States her pain level is 4 out of 10 after pain medication is administered
Lives alone
20 years ago Mrs. L’s mother had a hysterectomy but died 10 days after from surgical
complications
Objective Data
Abdominal dressing is stained with dried dark red drainage
V/S at 1200: T – 37.2 °C, P – 82, R – 22, BP – 130/76, O2 sat – 96 %
Fine crackles audible in lower bases of lung fields
Foley removed at 0600, has not voided since
Collaborative Care
Medications
o Morphine sulfate 5 mg IV Q3H PRN for pain
V/S Q4H
Activity: Ambulate to bathroom with assistance
Diet: Clear liquids
An incentive spirometer is at the bedside
At 1400 you assisted Mrs. L to the bathroom where she voided 400 ml. When she settled back into bed, Mrs. L requested pain medication which you administered at 1415. At 1800 Mrs. L states her pain level is 8 out of 10. You take out an ampule labeled hydromorphone 10 mg/mL and administer 0.5 mL to Mrs. L.
Explanation / Answer
SBAR is an acronym for Situation, Background, Assessment and Recommendation. This is a very useful tool for communication and famously used in healthcare settings amongst physicians and nurses. In this scenario;
Situation refers to patient's current conditions and this stage gives a brief introduction about the client. Here,it is about a 42 years old female Mrs.L who is one day post op total hysterectomy with remarkedly few changes vital signs like blood pressure and complains of pain intermittently with pain medications on course of treatment. She is under collaborative care including medications, nursing care.
Background here is the patient complains of pain and her mother who had passed 20 years ago 10 days post hysterectomy due surgical complications and she stays alone in her home. So, this must create an anxious state of mind and sense of fear. She needs emotional support and nursing care. Administration of painkillers to curb down pain and removal of Foley's to initiate self voiding.
Assessment, refers to Vital signs, pain score at different intervals and site of dressing for any changes of infection or inflammation, bleeding. Foley's removal and patient need assistance to use bathroom. Early ambulation to prevent from complications like DVT, pressure ulcer. patient is on clear liquids and voided urine in bathroom which is 400ml. Fine crackles present over lower lobes of lung fields. And on incentive spirometry of 1400. Reassessment of pain found to be 8 because of straining while walking to bathroom, thus need of pain killers as and when required and round the clock.
Recommendation for this patient is timely monitoring her vital signs along with her emotional state. Pain monitoring is mandatory because of the recent surgical procedures and administration of pain killers on timely manner. Delivering nursing care with taking care of her emotional state is important.
SBAR tool is a very effective way of communicating and things are clearly documented on the SBAR Tool which can add to a reference.