SBAR OB CE 6 Case Study Abdominal Surgery

SBAR OB CE 6 Case Study Abdominal Surgery Before filling out the template, first save the file on your computer. Then open and use that version of the tool. Otherwise, your changes will not be saved. Template: SBAR S Situation: What Is the situation you are calling about (End of Shift Report)? • Identify self, unit, patient, room number. • Briefly state the problem, what Is it, when it happened or started, and how severe. Hi I am nurse …., 49 y/o female, T.C., admitted to unit from the postanesthesia care unit (PaCU) after an exploratory laparotomy, is in room ….. 3 weeks ago underwent a vaginal hysterectomy and right salpingo- oophorectomy for abdominal pain and endometriosis. Postoperatively, she experienced an intra abdominal hemorrhage, requiring transfusion with 3 units of packed red blood cells (RBCs). After discharge, she continued to have abdominal pain, chills, and fever. She was readmitted twice: first for treatment of postoperative infection and second for evacuation of a pelvic hematoma. Despite treatment, T.C. continued to have abdominal pain, chills, fever, and nausea and vomiting. Dr. Jersey has placed post-op orders and directions on when to call her. B Background: Pertinent background information related to the situation could include the following: • The admitting diagnosis and date of admission • List of current medications, allergies, IV fluids, and labs • Most recent vital signs • Lab results: provide the date and time test was done and results of previous tests for comparison • Other clinical information • Code status VS: BP 130/70 P 94 RR 16 Temp: 99.7 F (37.6 C) SpO2 93% with oxygen 2L by nasal cannula Pain is an 8 on a scale of 1 to 10. NKDA Receiving an IV of 1000 mL D5.45NS at 100 mL/hr in her left forearm, with no swelling or redness. Receiving IV morphine sulfate for pain control through a patient-controlled analgesia (PCa) pump. The settings are dose 2 mg, lock-out interval 20 minutes, 4- hour maximum dose of 30 mg, A Assessment: Whal is the nurse's assessment of the situation? Respirations are shallow and her Spo2 is 93% with oxygen at 2 L by nasal cannula. A respiratory rate below 12 would indicate that T.C. is hypo-ventilating. T.C might require Narcan. Monitoring for respiratory depression is crucial when receiving morphine. Easily aroused and oriented to place and person, dozes between verbal requests. She has a low-midline abdominal dressing that is dry and intact and a Jackson Pratt drain that is fully compressed and contains a scant amount of bright red blood, foley to down drain has clear yellow urine This study source was downloaded by from CourseH on :41:35 GMT -05:00 6-Case-Study-Abdominal-Surgery-docx/ This study resource was shared via CourseH R Recommendation: What is the nurse's recommendation or what does he/she want? Examples: • Notification that patient has been admitted • Patient needs to be seen now • Order change • Educate her how to use Incentive Spirometry, how often to use it and what it is used for; She should use it 10 times per hour, take slow deep breaths in and try to keep the inhale steady. It is used to open the alveoli to promote oxygenation and prevent pneumonia. • Sit her up to a fowlers or semi-flowers position • Promote airway clearance by encouraging coughing and oral/oropharyngeal suctioning if necessary • Ensure that all equipment is working properly • If none of those interventions work, raise her nasal cannula until oxygenation is greater than 94%. • If her respirations drop below 12 she needs to be taken off the PCA pump. Other measures to help with pain: • Therapeutic massage • Repositioning • Mind-body techniques • Music therapy Patient education regarding wound care. Signs and symptoms of wound infection include increased pulse rate and temperature; an elevated white blood cell count; wound swelling, warmth, tenderness, or discharge; and increased incisional pain Take all medications as prescribed Call PCP if any fever, foul cloudy drainage occurs, sever pain, or any other concern. Keep all appointment with PCP and OB/GYN Institute for Healthcare Improvement • lhl,org I This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials In the spirit of patient safety, and please retain this footer In the spirit of appropriate recognition