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NR NR224 Simulation I-SBAR CHAMBERLAIN COLLEGE OF NURSING Simulation I-SBAR: Chamberlain College of Nursing

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by

Liu
in

 

I – Introduction

  • Your Name: Diamond Dorsey
  • Your Title: Student Nurse
  • Reason for Being There: Clinical Rotation

S – Situation

  • Patient: V.L.
  • Age: 76 years
  • Gender: Female
  • Height/Weight: (Not provided)
  • Allergies: NKDA (No Known Drug Allergies)
  • Code Status: Full Code
  • Privacy Code: (Not provided)
  • Time: 2000 hours
  • Attending Physician: Nikolaos Diakos, MD
  • Chief Complaint: NSTEMI (Non-ST Elevation Myocardial Infarction)

B – Background

  • Past Medical History:
    • Blood Transfusion
    • Breast Cancer
    • Cardiomyopathy
    • Congestive Heart Failure (CHF)
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Coronary Artery Disease (CAD)
    • Hyperlipidemia (HLD)
    • Hypertension (HTN)
    • Mitral Regurgitation (MR)
    • Obstructive Sleep Apnea (OSA)
    • Peripheral Artery Disease (PAD)
    • Status post-bypass surgery
    • Stroke

Current Medications:

  • Albuterol HFA
  • Amlodipine
  • Atorvastatin
  • Clonidine
  • Clopidogrel
  • Colace
  • Duo-neb
  • Isosorbide Mononitrate
  • Nitroglycerin
  • Ranolazine
  • Stiolto
  • Aspirin
  • Famotidine
  • Lyrica

Social History: (Not provided)

A – Assessment

  • Vital Signs:
    • Blood Pressure (B/P): 133/64 mmHg
    • Heart Rate (HR): 76 beats per minute
    • Respiratory Rate (RR): 26 breaths per minute
    • Temperature (TEMP): 98.1°F
    • Oxygen Saturation (SpO2): 96% on room air
    • Pain Level: 0/10
  • Falls Risk: Yes
  • Accu Check: Not provided
  • IV Site:
    • Right Forearm
    • Right Antecubital Fossa
  • IV Fluids: Normal Saline (NS)
  • Isolation Precautions:
    • Contact: No
    • Airborne: No
    • Droplet: No
  • Respiratory:
    • Decreased air entry bilaterally at the lung bases
    • No wheezing or crackles noted
  • Cardiovascular:
    • Heart rate normal and regular
    • No murmurs, gallops, or rubs detected
  • Neurological:
    • Patient is alert and oriented to person, place, and time (A&O x3)
    • No focal neurological deficits
    • Able to move all extremities without difficulty
  • Gastrointestinal/Genitourinary (GI/GU):
    • Abdomen is soft, non-tender, and non-distended
    • Positive bowel sounds (BS) present in all quadrants
    • Intake and Output (I&O) being monitored
  • Integumentary:
    • Skin warm to touch, with multiple blood-filled blisters noted on feet
    • A large fluid-filled blister observed on the left posterior aspect
  • Psychological:
    • Patient appears awake, alert, and in no acute distress
    • Engages appropriately with the healthcare team
  • Family/Support:
    • Patient is supported by her son, who is present and involved in her care
  • Safety:
    • Patient education needed on bed rest and the importance of calling for assistance
    • Non-weight bearing (NWB) status emphasized to prevent falls
  • Labs/Tests:
    • Abnormal Results:
      • Complete Blood Count (CBC)
      • Basic Metabolic Panel (BMP)
      • Computed Tomography (CT) of the abdomen
      • Chest X-ray (CXR)
    • Pending Results: Not specified

R – Request/Recommendation

  • Monitoring:
    • Continue monitoring ventilator settings if applicable
    • Regularly assess peripheral pulses and respiratory status
  • Medications:
    • Continue administration of prescribed blood thinners
  • Wound Care:
    • Maintain current wound care regimen for blisters
  • Hand-Off Report:
    • To be given to Professor Ufundo
    • Report provided by Diamond Dorsey, Student Nurse