Question

For the Case Scenario Analysis using SBAR, ONLY a chart with columns may be used to answer the questions. DO NOT answer in paragraph format. An example of how to set up a chart (you may use as many columns and/or rows as you wish and label accordingly):

		Major Issues	Missing Information	Nursing Actions Taken

    

1. Based on the following Case Scenario, complete a comprehensive end of shift hand off report using the SBAR format. In your report include:

a. The major issues of the case scenario

b. The information missing from the case scenario

c. As the nurse taking care of the patient, what actions did you take? Include this information in the appropriate section of the SBAR for your Handoff Report.

2. You may need to “make up” some information to complete the chart and answer these questions

You have been working a 12 hour day shift providing care for Mrs. S, a 72 year old female admitted 2 days ago with congestive heart failure.

Subjective Data

• Denies pain

• Began complaining of nausea at 0600

• States “I have had trouble breathing all night and was kept awake with a dry cough”

Objective Data

• Vital signs at 0600: T – 36.4 °C, P – 110 and irregular, R – 34, BP – 150/100, pulse oximetry – 94 % with oxygen @ 3 L/min via nasal prongs

• IV site looks slightly puffy but has good blood return

• Crackles heard in both lungs

• 3+ pitting edema in both legs and sacrum

Diagnostic Studies – results received at 0900

• Serum K+ 3.0 mEq

• Na+ is 135

• Digoxin level 2.4

Collaborative Care

• IV D5/0.45 NS 1000 ml with 20 mEq KCl q12h L hand # 20 g

• Medications o Digoxin 0.25 mg PO QAM o Furosemide 40 mg IVPB BID o K-Dur 10 mEq PO BID o Captopril 6.25 mg PO TID o Colace 100 mg PO QAM o NTG SL 0.4 mg 1 tab q5min x3 doses PRN for chest pain

At 0900 Mrs. S was alert but experiencing increasing shortness of breath, cough, and nausea and complaining of blurred vision. At 0900 her VS were: pulse oximetry 88%, P 116 and irregular, R 34 and short and shallow, BP 152/100. Her skin cool with slight cyanosis. You called the physician and received new orders.

Answer 1

SBAR YOPOTE calltng about Cwouan): Mr.s A ge Ser :Female Stuetion (S) 1 am daye ago. 2 aduission Date of The roblem Cangertrve heart fatlme cF) Calltrg about OM is s I have just Made as sesment:- Vitale siqne ave- 152 too MM (eregalay) pulse RRi- 3y Cshort shallou) synrlans Skin is cool aith anaru. Mw.S empevteucing tncreased tough. blurred SOB) nause a vision ab values SY-Kt 3.0 MEN SY.Nat 135 MEY

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Level MYs S sinie u4geting biurred uiteo v site At oite obser ved slight but Blood return geod When Iv site to be changed blo od tehurnSnot When the and Mrr S good having pain and inflamation fthroubo plebitie aw not cure but the Pt MYs S problem is bat pti tatu ig deterio- Troblem be helated to:- cardeac, 0edema, cligoxin over dose pulwonary Recommondationses CR) stqueet tthe plan of I suggest or Need chavgs hiX cave 3 DiORin doce Concerned about 3

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chert ay left ventrieular ejechon frothion (LVEP) EC4EKG Monitor vitale eqularly MYs. SBP teaches 15 2100 which needs immediate treatment cheit pain foy the Monitor for patient IMmediate call for phystcian wovsentug aud phyetan as pat eut con dthon deterionatng hew ovdevs. eggorted