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Student Name: ANGELA MCCUE Date: 4/05/19

4853L SBAR Clinical Worksheets

S Situation Priority # Priority #

Pt. Initials MM – independent TA – independent


Age 41 y/o male 56 y/o female
Room # 8404-A 8405-B
Admission date 3/30/19 4/4/19
Diagnosis Pneumonia and Sickle Cell Crisis which was resolved SBO
Allergies before being transferred to 8W ext. Shellfish, penicillin, tape, avelox, Percocet, Percodan
NKA Full code
Full Code
B Background CXR – 4/3 – pulmonary emboli and atelectasis No surgery or procedures recently - 1 yr. post colon
improving resection w/ colostomy
Surgery / date CXR – 4/5 – clear enough that thoracentesis is not No isolation or precautions
Recent procedures needed, and patient is able to be discharged to HX – ADHD, CHF, Chiari I Malformation, Depression,
Isolation/precautions home with PO antibiotics DJD, emphysema/COPD, lyme disease, lymphedema,
No isolation or precautions OSA, home oxygen and thyroid disease, Stomal Hernia
Hx Chronic Illnesses CT abd – SBO
HX – sickle cell anemia, Neg blood cultures

A Assessment Respiratory – lung sounds clear but diminished in all GI – abdomen soft w/ tenderness in LUQ and around
lobes anteriorly and posteriorly, Normal rate and stoma. BS hypoactive in all quadrants. Small –
Target assessment is: depth. RR 14. No cough. Denies SOB upon moderate amount of stool in the colostomy bag. N/V.
exertion or at rest. Complains of severe headache, PERRL, face
AOx4, 90/60, HR 65, RR 14, temp 98.6, 98% on RA. symmetrical, hand grasps moderate bilaterally. Full
Mental status Pain 7/10 offered Tylenol 650 mg PO but refused sensation in BUE.
Vital signs/ Pain stating he wanted Dilaudid. Using my judgement, I AOx4, 98 temp, 92% on 4 L NC, 76 HR, 128/68, 18 RR.
O2 therapy informed the patient that I was not able to give him Pain 7 (650 mg Tylenol PO), reassessed 4. Pain 8 (1
Pulse Ox O2 Sat Dilaudid based on his BP/HR/RR being on the low mg Diluadid IVP), reassessed 2 and remained a 2 for
I& O end of normal. Patient was not happy about this remainder of shift.
Labs / Blood glucose but still refused the Tylenol. Patients vitals Intake – 600, output -- 3 urines, medium amount of
IV therapy continued to remain low and patient continued to stool
refuse Tylenol for any pain score he reported K 3.4, albumin 3.0, RBC 338, H/H 10.3/32.9, PT/INR
No labs drawn on DOC. 11.8/1.0
No IV site d/t infiltration of Levaquin LR continuous at 100 ml/hr in L hand. R AC removed

R Recommendations Repeat CXR to determine if thoracentesis was


needed Dilaudid 1 mg IVP q3h, 650 mg Tylenol PO q4h
Interventions Zofran 4 mg IVP q4h, Tigan 200 IM q6h
New orders New Orders – discharge to home on PO antibiotics
Teaching New Orders: discharge to home
Calls to MD Education – Dilaudid and the effects on his
BP/HR/RR and the possible consequences if given Education of diluting Dilaudid and pushing slowly so
the pain medication that she wouldn’t become nauseous from it.
2 Desired outcomes
Patient will report a pain of 3/10 on DOC Patient will report a pain level of 2 or less on DOC
‒ Goal not met: pt continued to rate his ‒ Goal met
pain as 6-7/10
Evaluation of Patient will have 0 incidences of vomiting on DOC
outcomes Patient will verbalize understanding the effects of Goal met
Pain Medication on his already low BP/HR/RR
‒ Goal met