What is an SBAR for this patient?

What is an SBAR for this patient? Maria Hernandez 6-year-old female, weighing 39.6 lbs. with a history of Sickle Cell Disease. She has presented to the ED in sickle cell crisis and has a history of UTIs. Vital signs: Temp 101.8, B/P 131/79, HR 108, PaO2 87% room air, RR 51. Educational Needs Increased acuity Status assessment reports patient needs to know to prevention steps (i.e. good hydration) of sickle cell crisis. Health Increased acuity Status assessment reports patient in sickle cell crisis. LOC Normal acuity Status assessment reports no indication of increased LOC acuity Pain Increased acuity Status assessment reports patient in sickle cell crisis which is painful. Psych Normal acuity Status assessment reports no indication of increased psychiatric acuity Safety Increased acuity During sickle cell crisis patient is a fall risk Acute discomfort True Patients in sickle cell crisis experience pain Alteration in gas exchange True Status assessment reports PaO2 of 87% with RR 51 Altered skin integrity False Patient is at risk for altered skin integrity. Potential for delayed development True Due to chronic illness and possible frequent hospitalizations Safety Description Your Response Explanation Anxiety True Patient is at risk for anxiety related to Sickle Cell Crisis. Potential for infection False Status assessment reports no indication of Infection, high risk for sepsis. Assessment reveals: left knee swollen, red, and tender to touch. Pain is rated 9/10. Temperature is 102.3, RR 49, B/P 130/74, HR 110 pulse oximeter is 86% on room air. Maria is crying, unable to be consoled. Her mother is very anxious. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Start O2 per face mask at 4 L/min Sickle cell crisis occurs and limits oxygenation of tissue resulting in hypoxia and increased pain 2 2 Obtain urine specimen for urinalysis and culture and sensitivity Should be taken prior to trauma of needle stick (lab draw) 3 3 Start IV and draw CBC, BMP This avoids multiple sticks (related to IV fluids altering lab values) and gives baseline lab work to determine other issues or infections 4 4 Initiate IV fluids d5 ½ NS at 75 ml/hour IV hydration is needed to prevent dehydration 5 5 Administer Morphine Sulfate 4 mg/IV per MD order Relieve intense pain of sickle cell crisis Six hours later, on the pediatric floor, the mother is asking how they could have prevented this crisis from happening. Vital signs are improved, the child states pain is now a 2/10 in her left knee. Urinalysis comes back positive for bacteria. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Ask the mother what she knows about sickle cell crisis and triggers for this disorder Obtain baseline information before initiating teaching 2 2 Assess the child’s nutritional status through a 24- hour diet recall (child prefers chicken nuggets, French fries, and soft drinks for lunch) Poor nutrition can play a role in a sickle cell crisis 3 3 Ask the child what she most likes to drink Caffeinated drinks can cause dehydration 4 4 Provide additional information on nutrition, hydration, prevention of illness to the mother The assessment of the mother and child demonstrates the need for further teaching and reinforcement of teaching 5 5 Based on education, provide the child with healthy options for fluid intake The child needs to stay hydrated to reduce change of another sickle cell crisis Urinalysis report reveals 3+ bacteria, trace amount blood, trace amount protein, cloudy in appearance. The child weighs 48 pounds. The child and mother state that she does not drink a lot of water, but she does drink a soft drink every day. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Educate mother and child about signs/symptoms and treatment of UTI Early identification and treatment of UTI can prevent a possible sickle cell crisis 2 2 Initiate PO Bactrim 40 mg/kg in 2 divided doses Needed to treat UTI 3 3 Stay with patient for first 30 minutes to assess for adverse reaction to Bactrim such as rash, itching, or wheezing Watch for allergic reaction as first time she has had the antibiotic 4 4 Encourage clear fluids Ensure hydration to reduce chance of sickle cell crisis 5 5 Document teaching and medication Legal document, needed as part of the medical record Maria states that she is having a hard time breathing, and it hurts to take a deep breath. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Raise head of the bed Makes breathing easier for the child 2 2 Assess vital signs – HR 88 B/P 1010/72, RR 44, shallow, T 100.9 O2 sat 89% on room air Need baseline assessment values to determine cause of symptoms 3 3 Administer O2 at 6 L/min via nasal cannula Need to increase O2 saturation to > 90% 4 4 Assess lung sounds – decreased right lower lobe, some crackles noted Continued part of the respiratory assessment 5 5 Perform chest physiotherapy as ordered Helps to loosen secretions Maria has an order for 2 units of PRBCs to be infused. The blood has arrived on the unit. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Assess vital signs Needed for baseline values 2 2 Administer diphenhydramine 12.5 mg and acetaminophen 250 mg PO Needed to prevent transfusion reaction 3 3 Check blood with another nurse and compare to patient’s identification Safety for blood transfusion 4 4 Administer blood product Replace blood with new PRBC to increase o2 carrying capacity 5 5 Reassess vital signs Ensure patient is stable following transfusion DOB: 3/14/2016 (6yo) MRN: 82911040 Diagnosis: Sickle Cell Allergies: None Provider: Dr Childs Weight: 39.6 lbs Vital Signs Heart rate: 61 Temperature: 99.1 Pain level: None Respiratory rate: 25 BP: 119 / 67 Nauseated: Yes What is the amount of Acetaminophen, Childrens (Tylenol) 160mg/5mL oral sol to administer? 5.6 mls What is the amount of trimethoprim-oral sol (Bactrim) 40mg/5ml oral sol to administer? 6.8 What is the amount of morphine-IV (morphine) 1mg/mL IV to administer? 3.6

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