University:
The University of Texas Medical Branch
Course:
4503 | Adult 3
Academic year:

2023
Views:

191

Pages:

1
Author:

Dwayne Osborne

SBAR SHIFT →SHIFT REPORT This form is to assist in performing complete, precise patient hand off from shift to shift. Situation Patient Name: Marilyn Hughes Room: N/A Age: 45 Sex: Female Physician: N/A Admitted from: PACU (home, nursing home, assisted living, etc.) Background Admission Diagnosis/date: Lower leg fracture Date of Surgery (if applicable): 8 October 2021 Pertinent past medical history/dates: No prior medical history Assessment Code Status: Full code (advance directives, DNR) Diet: Clear liquids, advance to regular V.S. Pulse: 95 Blood pressure: 152/91 mmHg Respirations: 21 SpO2: 97% Temp: 99 F (37 C) IV site – lock/fluids/site/drips/when to change IV site: Right arm: peripheral IV, 20 g, Lactated Ringer’s Solution – 75 mL/hr Right hand: peripheral IV, saline lock, 20 g, Procedures done in the last 24 hours (include any known results): open reduction with internal fixation Abnormal Assessments: patient had a pain rating of 9 out of 10; patient’s blood pressure was elevated at 152/91 mmHg; patient’s lower left leg looked cyanotic and there was prolonged capillary refill in the toes on the left side Abnormal Lab/Radiology values: no labs were ordered for this patient Current pain score: 9 out of 10 What has been done to manage this pain: patient was administered morphine, but she verbalized she was still in pain; dressing on her left leg was loosened, and the pillow was removed from under her leg Safety needs/fall risk /skin risk/isolation precautions, etc.: patient is fall risk due to not being able to put any weight on her left leg Recommendation Needed changes in the plan of care? (Diet, activity, medication, consult): Medication needs to be changed because the patient stated that she was still in pain even after receiving morphine; doctor should visit the patient immediately to reassess her leg to make sure she has not developed compartment syndrome What are you concerned about? I am concerned that the patient will develop compartment syndrome What did you do about your concern? I immediately phoned the provider What the next shift needs to be aware of: the next shift needs to be aware of the medications the patient is taking while in the hospital, about her pain, the assessment findings of the left leg

Marilyn Hughes SBAR

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