Question

please help me with a good SBAR for Kenneth Bronson and Marilyn Hughes?

 Patient Introduction

 Kenneth Bronson is a 27-year-old male who was just admitted to the Medical Unit from the Emergency Department. He presented to the Emergency Department two hours ago with chest tightness, difficulty breathing, a productive cough for a week, and fever. Chest x-ray revealed right lower lobe pneumonia. IV was started of normal saline at 75 mL per hour. He is receiving oxygen at 2 L/min per nasal cannula. SpO₂ on room air was 90%, which increased to 95% with supplemental oxygen. He had a temp of 102.6' F and was given acetaminophen 1,000 mg in the Emergency Department.

Pharmacy just delivered the antibiotics to be given.

Patient Introduction

Marilyn Hughes is a 45-year-old female who suffered a left mid-shaft tibia-fibula fracture when she slipped on icy stairs this morning. She was taken to surgery for an open reduction with internal fixation (ORIF). She returned from surgery at 1:45 p.m. with a below-the-knee ace/splint dressing. Vital signs have been stable, and neurovascular checks have been within normal range. She has an IV of Lactated Ringer's infusing at 75 mL/hour and is tolerating liquids well without nausea. Her diet could probably be advanced to regular dinner this evening. A family member has been with her at the bedside throughout the day. She began complaining of pain shortly after returning from surgery and was given morphine 6 mg IV at 2:15 p.m. She is now on every-30-minute postoperative vital signs. Last vital signs were BP: 130/82, HR: 88, RR: 16.

Answer 1

SBAR for Kenneth Bronson

1.SITUATION ;

Recieved the patient,Mr,kenneth Bronson 45 years old, to the medical unit from the Emergency Department at 10am. Patient is concious and oriented during admission.

Patient has complaints of chest tightedness,difficulty in breathing ,productive cough fo a week and fever.oxygen is flowing through the nasal canula at the rate of 2L/Min.

2.BACKGROUND;

Patient has no relevent history of diabetes,hypertesion or other life style diseases.no relevent history of previous hospitalistion.

3.ASSESSMENT;

On asessment patient seems restless due to breathing difficulty ,the temperature was102.6' F. Chest x ray revealed right lobar ppneumonia.Spo2 on room air was 90% Which increase to 95% with supplimental oxygen.

Productive cough presnt with thick sputum,wheezing present on auscultaion.

4.RECOMMENDATION;

  IV infusion startes with normal saline75ml/hour,oxygen was recieving 2l/hour.

acetaminophen1000 mg was given in the emergrncy deparment.continous vital signs and spo2 monitering was started.Proped up position was given to the patient.catheterised the patient and NPO initiated.Atibiotics started and send to pharmacy,to be given.

SBAR for Marllyn

1.SITUATION

Recieved the patient, MRS,Marlln  from operation theatre at 1.45 pm with a below the knee ace splint dressing.Patient was undergone surgery for ORIF. the patient was came to the casuality with the history of fall from staires on this morning and diagnosed as mid shaft tibia-fibula fracture .during admission ,patient is concious ans oriented.vital signs and neurological status are stable.

2.BACKGROUND;

Patient has no hisory or hospitalisation inthe past,no significant histeoy of other diseases.

3.ASSESSMENT ;

Vital signs are checked and recorded bp-130/82mmhg,HR-88bts/min,respiration 16breaths/min.

Patient's GCSscore was15.Surgical site is normal,no abnormal drainage from the dressing.

4.RECOMMENDATION;

IV RL was infusing 75ml/hour and tolerating liquid without nausea.one family member was allocated with the patient through out the day.

patient began complaining of pain shortlyafter returning from surgery and was given morphine6mg iv at 2.15pm.

she is on continuous monitering of post operative vital signs.Her diet should beprobably advanced to regular dinner in this evening.