Loyola University Chicago
ATI Real Life Clinical Reasoning Scenarios
Care Plan/SBAR/Debrief Reflection
Directions: Completion of a Care Plan, SBAR and Debrief Reflection (provided here) is part of the clinical
make-up assignment (refer to the Individual Student Assignment Tasks on the Real Life 3.0 Scenario
lesson plan).
The following completed documents are required for evaluation: Individual Score report (Satisfactory
achievement); All Active Learning Templates (ALT’s); Care Plan; SBAR; and Debrief Reflection.
Email all completed documents to Course Director and Clinical Instructor by 5pm (CST) the night before
the next clinical day- unless instructed otherwise by the Course Director.
*Bring the completed Care Plan, SBAR, Debrief Reflection and Clinical Documentation form in hard copy
to the next clinical day and be prepared for debrief with the clinical instructor.
Care Plan
Assessment Findings Diagnosis/Problem/Analysis Plan Implementation Evaluation
back ache, burning At risk for preterm labor Check for effacement and Vaginal exam to - no dilation and
sensation when going to cervical dilation check for effacement
bathroom, uterine effacement and
contraction dilation
2 cm dilated and small At risk for preterm labor Administer Monitor uterine contractions
amount of bloody nifedipine contractions, should decrease
vaginal discharge uterine
contractions
should decrease
late decelerations on fetal uteroplacental insufficiency - position the client in Monitor fetal HR Fetal HR is within
monitor a lateral position to normal range with no
improve perfusion to late decelerations
the fetus
- increase lactated
ringers to increase
, circulating blood
volume
- assess the frequency
of uterine
contractions
- place oxygen on
client
Loyola University Chicago
Patient Presentation - SBAR Format
S (Situation):
● Age / Ethnicity / Gender:
● Reason for admission / Admitting Diagnosis:
● Surgical Procedure (If Applicable) / Date or POD?
B (Background):
● Past Medical History (PMH):
● Past Surgical History (PSH):
A (Assessment): (Relevant Data ONLY)
● Vital signs: within expected range
ATI Real Life Clinical Reasoning Scenarios
Care Plan/SBAR/Debrief Reflection
Directions: Completion of a Care Plan, SBAR and Debrief Reflection (provided here) is part of the clinical
make-up assignment (refer to the Individual Student Assignment Tasks on the Real Life 3.0 Scenario
lesson plan).
The following completed documents are required for evaluation: Individual Score report (Satisfactory
achievement); All Active Learning Templates (ALT’s); Care Plan; SBAR; and Debrief Reflection.
Email all completed documents to Course Director and Clinical Instructor by 5pm (CST) the night before
the next clinical day- unless instructed otherwise by the Course Director.
*Bring the completed Care Plan, SBAR, Debrief Reflection and Clinical Documentation form in hard copy
to the next clinical day and be prepared for debrief with the clinical instructor.
Care Plan
Assessment Findings Diagnosis/Problem/Analysis Plan Implementation Evaluation
back ache, burning At risk for preterm labor Check for effacement and Vaginal exam to - no dilation and
sensation when going to cervical dilation check for effacement
bathroom, uterine effacement and
contraction dilation
2 cm dilated and small At risk for preterm labor Administer Monitor uterine contractions
amount of bloody nifedipine contractions, should decrease
vaginal discharge uterine
contractions
should decrease
late decelerations on fetal uteroplacental insufficiency - position the client in Monitor fetal HR Fetal HR is within
monitor a lateral position to normal range with no
improve perfusion to late decelerations
the fetus
- increase lactated
ringers to increase
, circulating blood
volume
- assess the frequency
of uterine
contractions
- place oxygen on
client
Loyola University Chicago
Patient Presentation - SBAR Format
S (Situation):
● Age / Ethnicity / Gender:
● Reason for admission / Admitting Diagnosis:
● Surgical Procedure (If Applicable) / Date or POD?
B (Background):
● Past Medical History (PMH):
● Past Surgical History (PSH):
A (Assessment): (Relevant Data ONLY)
● Vital signs: within expected range
