What is an SBAR for this patient?

What is an SBAR for this patient? Baby Strickland | Room 301 Patient Overview 1-hour-old newborn female, 37-week gestational age born via C-section, weight 9.9 lbs. Mom has history of diabetes, not well controlled. Educational Needs Increased acuity Status assessment reports uncontrolled diabetes. Health Increased acuity Status assessment reports mother is dx with diabetes and patient’s birth weight is 9 lbs. 13 oz. LOC Normal acuity Status assessment reports no indication of abnormal LOC Pain Normal acuity Status assessment reports no indication of Pain Psych Normal acuity Status assessment reports no indication of Psychiatric deficits Safety Increased acuity Status assessment reports baby large for birth and at risk for volatile blood glucose. Alteration in gas exchange False Patient is at risk for Impaired Gas Exchange if patient becomes hypoglycemic Alteration in skin integrity False Status assessment reports no indication of impaired skin integrity Alteration in thermoregulation True Status assessment reports patient is 1 hour old. Hypoglycemia True Status assessment reports mother is dx with diabetes and patient’s birth weight is 9 lbs. 13 oz. Ineffectual breathing pattern True Status assessment reports patient is 1 hour old and is 9 lbs. 13 oz. Assessment: baby appears jittery, temp 97.2 under warmer, RR 62, HR 160 You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Obtain heel stick blood glucose level – level is 35 assess BG based on baby symptoms to determine possible cause 2 2 Feed baby ½ ounce formula correct intervention for hypoglycemia 3 3 Notify lab for confirmation blood glucose level – value is 29 Protocol is to get confirmation but do not wait on confirmation prior to intervention for safety concerns 4 4 Recheck blood glucose in 45 minutes, value is 45 reassess to see if intervention was effective 5 5 Continue to monitor baby may have future episodes of hypoglycemia and should be carefully monitored Assessment: Vital signs RR 69, T 98.3, HR 170, retractions, grunting, and nasal congestion and flaring noted O2 sat 86%. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Position baby in Trendelenburg Promotes ease of breathing and drainage of secretions 2 2 Suction excessive secretions via bulb syringe and NG tube Removes excess secretions 3 3 Place under oxy hood at 40% Need to achieve O2 sat > 90% 4 4 Initiate IV D5 ¼ NS at 6 ml/hour Fluids to keep baby hydrated, access for IV medications if needed 5 5 Reassess respiratory system To see if interventions have been effective The baby is found in the parents’ room next to the air conditioner, with no blanket covering him. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Assess vital signs – Temp 97.2, RR 66, HR 160 Assessment determines need for interventions and provides information 2 2 Wrap baby in warm blanket and put hat on baby’s head Quickest way to gradually warm baby and prevent further heat loss 3 3 Reassess temperature in 15 minutes, Still 97.4 Determines if intervention was effective 4 4 Place baby in radiant warmer with temperature probe attached Further intervention was needed temperature probe is for safety 5 5 Educate parents on neonatal heat loss and how to prevent this Prevent further potential injury to the baby The baby has persistent hypothermia, low blood glucose, reduced sucking. A diagnosis of Sepsis is suspected. 1 1 Place infant in isolation radiant warmer Isolation to protect other infants. 2 2 Obtain ordered blood cultures blood cultures needed prior to antibiotic administration 3 3 Initiate IV Ampicillin per MD order Initiate IV Ampicillin per MD order, antibiotics fight to destroy the infection 4 4 Reassess Blood glucose BG = 38 BG levels fall in the presence of sepsis 5 5 OG feed infant 15 ml Infant Formula baby needs nutrition, but too weak to suck from a bottle Lab results for the newborn reveal a bilirubin of 12 mg/dl. You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanation 1 1 Place infant in triple phototherapy isolette phototherapy is needed to prevent injury from kernicterus 2 2 Place protective eye shields over the baby’s eyes safety to protect the infant’s eyes 3 3 Initiate the phototherapy treatment needed to decrease bilirubin levels 4 4 Feed infant every 2 ½ hours infants under bilirubin lights need more frequent feedings producing more bowel movements. 5 5 Document number of voids and stools per shift more frequent feedings will result in more frequent voids and stools, and is how bilirubin is excreted DOB: 9/28/2022 (0yo) MRN: 82911040 Weight: 9.9 lbs Diagnosis: Diabetes Allergies: NKDA Provider: Dr Childs Patient DOB: 9/28/2022 (0yo) MRN: 82911040 Diagnosis: Diabetes Allergies: NKDA Provider: Dr Childs Weight: 9.9 lbs Vital Signs Heart rate: 123 Temperature: 101.6 Pain level: Moderate Respiratory rate: 46 BP: 71 / 42 Nauseated: Yes What is the amount of ampicillin (Unasyn) 500mg/50ml IV to administer? 303.6 What is the amount of D5 0.25 NS (D5 0.25 NS ) 5% Dextrose IV 1000ml bag to administer? 7mls

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