Simulation I-SBAR
CHAMBERLAIN COLLEGE OF NURSING
Your Name:
I Your Title: RN
Reason for being there: to
Introduce yourself
perform an assessment
Patient: Rita Spankly
S
Situation
Age: 68
Gender: Female
Height/Weight : 175 cm/65.9kg
Allergies: N/a
Attending Physician: Dr Smiley
Patient Chief Complaint: total right knee arthoplasty
Code status: Full
Privacy Code:
Time: 8:00
Past Medical History- Chronic osteoarthritis, endovenous laser ablation last year for varicose
B
Background
veins
Current Medications: Calcium carbonate 600mg PO qAM, Meloxicam 15mg PO qAM
Social History: Retired receptionist, married for 35 years, denies use of alcohol, half a pack of
cigarettes a day for 45 years, quit four months ago, regular diet and minimal exercise.
Vital Signs:
A B/P
122/76
Falls risk: N/A
70
HR
26
Accu check: N/A
RR TEMP
98.6 98%
SP02
4/10
PAIN
IV Site: left arm IV Fluids: normal saline ___________________________
Isolation Isolation Precautions N Y Contact Air Droplet : N/A
RESPIRATORY Upon inspection of anterior chest, no accessory muscle used.. No abnormality in spine. AP
is less that transverse diameter. Denies shortness of breath. Lung sounds clear to
auscultation
CARDIOVASCULAR No JVD noted.. Capillary refill less than 3 seconds, no murmurs, gallops or rubs present.
Regular rate and rhythm
NEUROLOGICAL The patient is AAO X4. She can follow commands. Eyes are normoactive to light.
PERRLA is intact .Speech, facial expressions, mood and affect are appropriate for the
situation. RLE 3/5, 1+ pitting edema to the RLE, warm to touch and redness, pain during
palpation
GI/GU
I&O Upon inspection of the abdomen, the contour and symmetry is appropriate for the situation,
Abdomen is hyperactive during auscultation. Abdomen is firm, no pain, tenderness, scriae,
lesions, deformities. No bowel movement from last three days and no urinary continence
noted.
INTEGUMENTARY Clean and dry, skin color appropriate for ethnicity, no skin turgor present, Braden skin
assessment score was 15, mild risk for pressure injury
PSYCHOLOGICAL Her husband supports her
FAMILY - SUPPORT
SAFETY Teaching needs: ambulation is necessary
Abnormal:
LABS/TEST
Pending:
This study source was downloaded by 100000817935606 from CourseHero.com on 01-26-2022 15:07:37 GMT -06:00
https://www.coursehero.com/file/88739085/iSBAR-doc/
CHAMBERLAIN COLLEGE OF NURSING
Your Name:
I Your Title: RN
Reason for being there: to
Introduce yourself
perform an assessment
Patient: Rita Spankly
S
Situation
Age: 68
Gender: Female
Height/Weight : 175 cm/65.9kg
Allergies: N/a
Attending Physician: Dr Smiley
Patient Chief Complaint: total right knee arthoplasty
Code status: Full
Privacy Code:
Time: 8:00
Past Medical History- Chronic osteoarthritis, endovenous laser ablation last year for varicose
B
Background
veins
Current Medications: Calcium carbonate 600mg PO qAM, Meloxicam 15mg PO qAM
Social History: Retired receptionist, married for 35 years, denies use of alcohol, half a pack of
cigarettes a day for 45 years, quit four months ago, regular diet and minimal exercise.
Vital Signs:
A B/P
122/76
Falls risk: N/A
70
HR
26
Accu check: N/A
RR TEMP
98.6 98%
SP02
4/10
PAIN
IV Site: left arm IV Fluids: normal saline ___________________________
Isolation Isolation Precautions N Y Contact Air Droplet : N/A
RESPIRATORY Upon inspection of anterior chest, no accessory muscle used.. No abnormality in spine. AP
is less that transverse diameter. Denies shortness of breath. Lung sounds clear to
auscultation
CARDIOVASCULAR No JVD noted.. Capillary refill less than 3 seconds, no murmurs, gallops or rubs present.
Regular rate and rhythm
NEUROLOGICAL The patient is AAO X4. She can follow commands. Eyes are normoactive to light.
PERRLA is intact .Speech, facial expressions, mood and affect are appropriate for the
situation. RLE 3/5, 1+ pitting edema to the RLE, warm to touch and redness, pain during
palpation
GI/GU
I&O Upon inspection of the abdomen, the contour and symmetry is appropriate for the situation,
Abdomen is hyperactive during auscultation. Abdomen is firm, no pain, tenderness, scriae,
lesions, deformities. No bowel movement from last three days and no urinary continence
noted.
INTEGUMENTARY Clean and dry, skin color appropriate for ethnicity, no skin turgor present, Braden skin
assessment score was 15, mild risk for pressure injury
PSYCHOLOGICAL Her husband supports her
FAMILY - SUPPORT
SAFETY Teaching needs: ambulation is necessary
Abnormal:
LABS/TEST
Pending:
This study source was downloaded by 100000817935606 from CourseHero.com on 01-26-2022 15:07:37 GMT -06:00
https://www.coursehero.com/file/88739085/iSBAR-doc/
