Scenario: Mr. Smith is a 75-year-old man
Scenario: Mr. Smith is a 75-year-old man who lives at the long-term care home, Shady Acres, where you are an PN student. Upon entering his room to bring him to the dining room, you discover him lying the floor beside the toilet. He has a large bump on his forward and seems a bit confused. Upon assessment, he states he has pain in his head and left wrist. He feels cool and clammy and is upset about lying on the floor for so long. His vitals are as follows: BP 109/61, HR 58, RR 16, O2 97% on RA, Temp 37.1. You call for help and assist him to his bed using a mechanical lift. Upon further assessment, you see swelling and a slight deformity to his left wrist. Mr. Smith is more confused and yelling out to help him. You are concerned about Mr. Smith’s increasing confusion and that he may have broken his left wrist. Mr. Smith takes Aspirin 81 mg daily and has an allergy to Penicillin. You would like to call the physician about this incident. SBAR Template S Situation: (state in 5-10 seconds) State: Your name, unit and client name Briefly state the problem I am concerned about… B Background: State admission diagnosis and date of admission State pertinent medical history (Consider the following clinical information: procedure preformed, Medications client is taking, allergies) Provide a brief summary of treatment to date Client code status (if applicable) A Assessment: Vital signs Pain scale Is there a change form prior assessment R Recommendation: State what you would like to see done, or specify that the appropriate health care provider needs to come to assess the client. Ask the health care provider wants to order any tests or medications Ask the health care provider if they want to be notified for any reason In the case of no improvement, ask the health care provider when you should call again
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