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SBAR-PE05 - Homework help
Maternity and Pediatric Nursing (NUR 204)
Jersey College Nursing School
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SBAR: Situation-Background-Assessment-Recommendation Student Name Vanisha Lundy __________________________________________ Date 4/20/21_____________________
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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.
Vanisha , student nurse from walk in clinic calling regarding pt A who is currently present in the clinic and is being seen for a 2 day history of diffuse severe abdominal pain, nausea w/o vomiting, denies any vaginal discharge or bleeding
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
A reports having unprotected sex with several partners recently, two had had penile discharge. Last menstrual period ended 3 days ago. NKDA Denies previous medical or psychiatric problems Vs: 108/60, 110, 20, 100 f ( 38 C)
C/o of abdomen pain when touched
A
Assessment: Whal is the nurse's assessment of the situation? Pelvic examination reveals purulent material pooled in vaginal fault that appears to be coming from cervix which is consistent with Positive chlamydia results Pregnancy test completed which rules negative Treatment option selected for Zithromax 1g PO administered in clinic Explain all partneres needs to be treated according to the public health department Low literacy regarding safe sex and how STI’s are obtained Inquire if patient would like to be tested for HIV after
educating pt on the disease, pt agreed to test
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
Provide support, and education regarding STI’s and how to prevent them in the future Instruct patient to not have sex until she returns to the clinic to be retested Instruct the patient to return to clinic in 1 week to obtain HIV results and get retested for chlamydia after ABO therapy has been completed ( both test came back negative ) Educate patient on safe sex Follow up yearly with a gynecologist Educate pt on signs and symptoms to return to the clinic, if symptoms return
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SBAR-PE05 - Homework help
Course: Maternity and Pediatric Nursing (NUR 204)
University: Jersey College Nursing School
