SBAR OB CE 6 Case Study Abdominal Surgery
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SBAR: Situation-Background-Assessment-Recommendation Student Name Date
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Template: SBAR
Hi I am nurse …., 49 y/o female, T.C., admitted to unit from the postanesthesia
S Situation: What Is the situation you are calling
about (End of Shift Report)? care unit (PaCU) after an exploratory laparotomy, is in room …..
a
• Identify self, unit, patient, room number.
3 weeks ago underwent a vaginal hysterectomy and right salpingo- oophorectomy
vi
• Briefly state the problem, what Is it, when it
happened or started, and how severe.
for abdominal pain and endometriosis. Postoperatively, she experienced an intra-
abdominal hemorrhage, requiring transfusion with 3 units of packed red blood
cells (RBCs).
d
After discharge, she continued to have abdominal pain, chills, and fever. She was
e
readmitted twice: first for treatment of postoperative infection and second for
ar
evacuation of a pelvic hematoma. Despite treatment, T.C. continued to have
abdominal pain, chills, fever, and nausea and vomiting.
sh
Dr. Jersey has placed post-op orders and directions on when to call her.
Background: Pertinent background information
B VS: BP 130/70 P 94 RR 16 Temp: 99.7 F (37.6 C) SpO2 93% with oxygen 2L by
as
related to the situation could include the following:
• The admitting diagnosis and date of admission
nasal cannula Pain is an 8 on a scale of 1 to 10.
• List of current medications, allergies, IV fluids, and NKDA
w
labs
• Most recent vital signs
Receiving an IV of 1000 mL D5.45NS at 100 mL/hr in her left forearm, with no
swelling or redness.
m e
• Lab results: provide the date and time test
was done and results of previous tests for
•
comparison
co rc
Other clinical information
Receiving IV morphine sulfate for pain control through a patient-controlled
analgesia (PCa) pump. The settings are dose 2 mg, lock-out interval 20 minutes, 4-
hour maximum dose of 30 mg,
o. ou
• Code status
er res
Assessment: Whal is the nurse's assessment of the Respirations are shallow and her Spo2 is 93% with oxygen at 2 L by nasal
A situation? cannula.
eH y
A respiratory rate below 12 would indicate that T.C. is hypo-ventilating. T.C might
rs ud
require Narcan. Monitoring for respiratory depression is crucial when receiving
morphine.
Easily aroused and oriented to place and person, dozes between verbal requests.
t
ss
She has a low-midline abdominal dressing that is dry and intact and a Jackson-
Pratt drain that is fully compressed and contains a scant amount of bright red
blood, foley to down drain has clear yellow urine
hi
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