SBAR Report from ED Triage nurse to

SBAR Report from ED Triage nurse to ED RN for Alec Morris-Abd trauma S-Alec Morris is an 17 year old adolescent who is vomiting and c/o abd pain after a biking accident B- Alec was biking with his buddies. He hit something in the roadway and went over the handle bars. He states he hit his head but didn’t lose consciousness. He was not wearing a helmet. Two hours later he was somewhat lethargic and began vomiting and c/o of the abd pain. His parents immediately brought him to the Emergency Room. Alec is an otherwise healthy adolescent who is up to date on his immunizations. He’s at the 50th percentile for wt and ht on his growth charts. His parent is at the bedside. No known allergies. Head/neckCT completed. Neck is cleared and collar removed. A- Alec has sustained abd and head trauma. He is in room 2. R-Alec needs immediate evaluation by the nurse including calculating the Revised Trauma Score, and as soon as possible by the MD. The MD will be in as soon as possible. He wants the basic protocol orders for abd and head trauma until he can get in to evaluate him. The orders are in the room for you. Use the Broselow chart for approximate weight. What targeted assessments will be needed? What potential complications could occur? What medications would treat common complications? What are the nursing implications of the ordered medications and medications to treat complications? Standing Orders for Pediatric Trauma Patients Maintain O2 sat of 92% with oxygen as needed Insert 2 large bore size appropriate IV’s Draw labs: CBC, coagulation panel, BMP (basic metabolic profile), Type and Cross Begin NS bolus of 20 ml/kg If suspected head injury: Record Glasgow Coma Scale q 15 minutes. SCIENCE HEALTH SCIENCE NURSING NURSING 985

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