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

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The University of Texas Medical Branch 4503 | Adult 3

Lecture Note

Marilyn Hughes SBAR

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