How do I make this scenario an SBAR???

[khrisrk]

Patient Profile:

The nurse has been working for day shift (12 hour). She provided care for Mrs. M, a 50 year old female who is one daypost op total abdominal hysterectomy. She will be giving the Report to the nurse working night shift.This is the information from her shift:

Subjective Data

- States her pain level is 4 out of 10 after pain medication is administered

- Single

- Mrs. M's mother had a hysterectomy and died 7 days after from surgicalcomplications

Objective Data

- Abdominal dressing is stained with dried dark red drainage

- V/S at 1200: T – 37.2 °C, P – 82, R – 22, BP – 130/76, O2 sat – 96 %

- Fine crackles audible in lower bases of lung fields

- Foley removed at 0600, has not voided since

Collaborative Care

- Medicationson Morphine sulfate 5 mg IV Q3H PRN for pain

- V/S Q4H

- Activity: Ambulate to bathroom with assistance

- Diet: Clear liquids

- An incentive spirometer is at the bedside

At 1400 she was assisted to the bathroom where she voided 400 ml. When she settled back into bed,Mrs. M requested pain medication which was administered at 1415. At 1800 Mrs. M states her pain level is8 out of 10. The nurse take out an ampule labeled hydromorphone 10 mg/mL and administer 0.5 mL to Mrs. M.

Can somebody help make these into an SBAR report? Please. Still a little bit confused as to which information to put in each category. Thank you!

[Julius Seizure]

Here is the basic idea, in my mind anyway -

Situation: Give me to 1-3 sentence summary of the patient and what we are doing right now. For example (I work in pediatric cardiac ICU): This patient is a 3 year old female, post-op day 2 from ASD repair. Right now we are working on increasing PO intake and getting off IV pain meds.

Background: Relevant medical history both prior to and during this admission. For example: Shes a former preemie (34 week gestation) and also has intestinal atresia. In the OR she had some ventricular tachycardia after they closed her chest incision but has not had any arrhythmias since coming to the ICU. Shes been ambulating well, voiding normally. Her chest tube was removed yesterday.

Assessment: Your physical assessment that you did on the patient (both the subjective and objective).

Recommendations: Anything that is currently pending or needs to happen next. For example: Labs are every 12 hours, so she will need a CBC and electrolytes drawn at 4am. She also has daily EKGs and chest x-rays and that are due at 6am. Her antibiotic is currently infusing and the pump should beep that its finished in about 15 minutes. I've really had to encourage her to walk and move around but she does it with encouragement. You might want to try having her blow bubbles instead since shes a little too young to understand how to use the incentive spirometer.