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Sbar - This is the SBAR I made for clinical it provides both physical assessment sheet

This is the SBAR I made for clinical it provides both physical assessm...

Course

Clinical Practicum I (NURS-1512)

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University

Lambton College of Applied Arts and Technology

Academic year: 2020/2021

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Lambton College of Applied Arts and Technology

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SBAR CLINICAL WORKSHEET

Student Name: Dates of Care:

S

Medical Diagnosis/and or surgical procedure:

(include definition and why surgery performed)

Significant past history:

Allergies:

Code status: Age:

Lab values:

de

ms)

Hgb 135-180 g/L Hct 0 - 0 (%) RBC 4.5-6 x 1012/L WBC 4-11 x 109/L Differential: Neutrophils 0.4-0: Lymphocytes 0.2-0: Monocytes 0.02-0: E inophil <0:

Sodium Potassium Chloride CO FBS BUN: Creatinine

Diagnostic

s ent)

Client Medication Information

(Drug name, Dose ordered, Normal Adult dose, Time ordered for, and Purpose and Nursing Implications)

Attach on a separate sheet

Priority Nursing Diagnosis. 3 Interventions for each diagnosis

1.

2.

3. In Collaboration with client identifies health teaching needs :

B

Background Transfer status □Mech Lift □ 1-person □ 2-person □ Independent Falls/Risk □Yes □No

Allergies □Yes □No Infection control □ MRSA □ VRE □ C-Diff □ Other Assistive devices_____________

Assessment GLUMS (ordered/how often) Diet and % of

meal taken

A

Vital

signs

T____ P_ R_ BP__ SPO 2 _ Time Result Time

Neurological Assessment Active Head Injury? Y/N Behaviour Appropriate for setting? Y/N Pupillary Reaction (PERRLA)

Level of Consciousness: Orientation: 1. Person Stimulus Needed? Y / N Stimulus: 1. Person 2. Place 3. Time _______

Cardiac Assessment Apical Pulse: Rate: __________ Rhythm: _________________ S1 and S2 audible: ___________ Abnormal sounds: _________________________

Neurovascular Assessment (6P’s) Pulse: Paresthesia: Pain: Paralysis: Pallor: Paresis: Left Arm - Right Arm – Capillary Response: Capillary Response: Edema: Edema: Limb strength: ________________________ Limb strength: ______________________ Sensation: ___________________________ Sensation:

Left Leg - Right Leg – Capillary Response: Capillary Response: Edema: Edema: Limb strength: ________________________ Limb strength: ______________________ Sensation: ___________________________ Sensation: _________________________

Respiratory Assessment Chest Wall symmetry Shape of chest Lt Lung posterior AIR entry: Lt Lung post SOUND: Lt Lung posterior AIR entry: _________ Rt Lung post SOUND: _ Lt Lung anterior AIR Entry: Lt Lung ant SOUND: Rt Lung anterior AIR entry: ___________________ Rt Lung ant SOUND: _ Rt Lung laterally AIR entry: ___________________Rt Lung lat SOUND:

Pericardiocentesis also called a pericardial tap, is a procedure in which a needle and catheter remove fluid from the pericardium, the sac around your heart. The fluid is tested for signs of infection, inflammation, and the presence of blood and cancer

Cardiac tamponade is a serious medical condition in which blood or fluids fill the space between the sac that encases the heart and the heart muscle.

Cardioversion- is a medical procedure that restores a normal heart rhythm in people with certain types of abnormal heartbeats; is usually done by sending electric shocks to your heart through electrodes placed on your chest.

Unstable and stable Afib: Atrial fibrillation is an irregular and often rapid heart rate that occurs when the two upper chambers of your heart experience chaotic electrical signals. The result is a fast and irregular heart rhythm. The heart rate in atrial fibrillation may range from 100 to 175 beats a minute.

Bradycardia: is a slower than normal heart rate under 60 bmp.

Tachycardia s the medical term for a heart rate over 100 beats per minute.

Cardiac pause: or arrest — A sinus pause or arrest is defined as the transient absence of sinus P waves on the electrocardiogram (ECG) that may last from two seconds to several minutes (waveform 1).

Permanent pacemaker: is placed in your chest or abdomen that control heart beats its mainly used for those with slow HR.

Temporary transvenous pacing consists in inserting a temporary pacing electrode catheter into the right ventricle and then applying an electric stimulus with the goal of results in the delivery of an adequate heart rate and cardiac output

NSTEMI: is a type of heart attack. NSTEMI stands for Non-ST-elevation myocardial infarction refers to the ST segment, which is part of the EKG heart tracing used to diagnose a heart attack. STEMI: Elevation Myocardial Infarction ( STEMI ) is a very serious type of heart attack during which one of the heart's major arteries (one of the arteries that supplies

oxygen and nutrient-rich blood to the heart muscle) is blocked. ST-segment elevation is an abnormality detected on the 12-lead ECG

ACS (Acute coronary syndrome): refers to any group of clinical symptoms compatible with acute myocardial ischemia and includes unstable angina (UA), non— ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI).

FLYER (Term for patient going for angiogram in London)

An angiogram detects blockages using X-rays taken during the injection of a contrast agent (iodine dye).

Ejection Fraction: is a measurement in a percentage, of how much blood the left ventricle pumps out with each contraction.

CHF: is a chronic progressive condition that affects the pumping power of your heart muscle. While often referred to simply as heart failure.

Febrile Neutropenia: is the development of fever, often with other signs of infection, in a patient with neutropenia , an abnormally low number of neutrophil granulocytes (WBC).

Reverse Isolation: refers to the practice of healthcare workers and visitors wearing barriers (i.,, gown, gloves, mask, etc.) routinely upon entry to the client room, for the purpose of preventing client exposure to external microbes.

Ischemic: blockage in an artery that supplies blood to the brain. The blockage reduces the blood flow and oxygen to the brain, leading to damage or death of brain cells.

Hemorrhagic stroke: happens when a blood vessel bursts, causing bleeding in the brain. As the blood presses on brain cells, it damages them

TIA: is a stroke that lasts only a few minutes. It happens when the blood supply to part of the brain is briefly blocked.

Normal 12-lead EKG/ECG VALUES P Wave: Amplitude: 2-2 mm high (Or 2 squares) PR interval: Duration 0/012-0/20 sec Deflection: + in I, II, AVF, V2-V6 ST Segment: Duration: 0.08-0 sec Duration: 0 - 0 sec QT Interval: Duration 0.36-0 sec QRS Complex: Amplitude: 5-30 mm high Deflection: + in I, II, III, AVL, AVF, V4-V Duration: 0 - 0 sec T Wave: Amplitude: 0 mm in limb leads Deflection: I, II, V3-V Duration: 0 - 0 sec (Or greater)

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