SBAR FOR NURSING
REVIEW the follow patient information and complete an SBAR for the oncoming nurse (see student resource section for example and blank form of an SBAR) (90pts)
INSTRUCTIONS
Please make sure your name is on all assignments Along with the title of the homework (e.g. SBAR ) Patient name: Bob Bob DOB: 11/01/65 Att.
Physician: Brown, blue MD Admission date 09/01/18 Date of service 09/01/18 Room: 211 Account no: S001234567 History and Physical: Mr. Bob is Height 5 feet 7 inches and Weight is 150 kg Arrived at the emergency department on 09/01/1018 about 1 pm, after losing control of his vehicle. Bob arrived complaining of right hip pain, headache and blurred vision. When asked to explain what has happened, he was unable to concentrate, had some shortness of breath and urinated on himself, but state he and his wife was in a fight.
A look at past medical records indicates Bob is a type 1 diabetic, allergic to PCN, HIV diagnosed a year and a half ago and had recently been admitted to hospital for hypertensive crisis. He denies shortness of breath, No nausea or vomiting, and admit to non-compliance with his medication.
He takes Lantus 15 units subcutaneous daily, on an insulin sliding scale, Percocet 5/20mg p.r.n., and Labetalol. Blood pressure 140/90, heart rate is 100, respiratory 18, oxygen saturation 99% on room air, and temperature 98.2, His pupils are equal, reactive to light, extra ocular movement intact. No JVD, no peripheral edema noted.
Patient is schedule for Open reduction internal fixation of the right in the morning at 8 am. with Dr. Bigtime. LABS & Diagnostic test on admission Bob’s blood sugar was 660mg/dL Na 140mmol/L K 6.1mEq/L WBC 11.2/L RBC 4.24mcL HGB 13.3g/dL HCT 36.2% Creatinine 1.2mg/dL X-ray-broken right femur SITUATION- BACKGROUND ASSESSMENT RECOMMENDATION
