How to make this scenario in SBAR

Nurses General Nursing

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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!

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Why don't you show us what you have come up with so far?

When doing this, recall the individual categories reported using the SBAR and determine where each piece of data should be placed.

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Specializes in mental health / psychiatic nursing.

SBAR is Situation, Background, Assessment and Recommendation/Request.

S: Why are you calling/reporting this information? B: What background information is pertinent to understanding the situation? A: What assessment(s) have you done and what information have you gained? R: Based on this information what do you recommend or what would you like the person you are reporting to do?

Use these questions as you work through the scenario above and see if it makes more sense.

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Why don't you show us what you have come up with so far?

When doing this, recall the individual categories reported using the SBAR and determine where each piece of data should be placed.

Hi Chare,

Thank you! This is what I came up right now.

S - Mrs. M, a 50 year old female who is one day post op total abdominal hysterectomy.

B - Mrs. M's mother had a hysterectomy and died 7 days after from surgical complications. She is single.

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

- 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. At 1400 she was assisted to the bathroom where she voided 400 ml.

- pain medication which was administered at 1415.

- At 1800 Mrs. M states her pain level is 8 out of 10.

B - Assess pain after an hour.

- Ask for increased pain medication.

- Call MD for chest x-ray.

Is there anything else you think I should add to my answer? Or areas to improve?

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As to your scenario, and SBAR.

Situation: This is fine.

Background: This is fine, to start.

Assessment: Move everything related to the Foley catheter removal and subsequent voiding to background. Also, this is contradictory information. Move everything related to the 1415 pain event to background.

Recommendation: Have you treated the 1800 pain event? If not, do so prior to calling the physician. Regarding the chest x-ray (and crackles); has the patient been using her incentive spirometer? If not, why? If the patients previous pain was 4/10 after treatment, and her current pain level is 8/10 do you think this might affect her respiratory status? These are questions that the physician will likely ask you.

Where do you think the following should be included?

•V/S Q4H

•Activity: Ambulate to bathroom with assistance

•Diet: Clear liquids

•An incentive spirometer is at the bedside

What medication should she be receiving? She has morphine, 5 mg IV ordered, yet you state that she received hydromorphone, 5 mg IV.

The SBAR report format was originally implemented in the U.S. Navy's nuclear submarine service as a means of quickly reporting pertinent information during a critical event. From there, the airline industry adopted it, as did others. Kaiser Permanent introduced it for use by its rapid response teams in 2002. Then, with the move to standardize communication a growing number of facilities began implementing the SBAR formation for end of shift handoff. As you can see from the example provided, it becomes clunky and unwieldy, making it a poor tool for this purpose. In my opinion, the I PASS the BATON format is much more useful for end of shift handoff.

If you haven't visited it yet, you might find the Institute for Healthcare Improvement's SBAR Toolkit helpful.

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As to your scenario, and SBAR.

Situation: This is fine.

Background: This is fine, to start.

Assessment: Move everything related to the Foley catheter removal and subsequent voiding to background. Also, this is contradictory information. Move everything related to the 1415 pain event to background.

Recommendation: Have you treated the 1800 pain event? If not, do so prior to calling the physician. Regarding the chest x-ray (and crackles); has the patient been using her incentive spirometer? If not, why? If the patients previous pain was 4/10 after treatment, and her current pain level is 8/10 do you think this might affect her respiratory status? These are questions that the physician will likely ask you.

Where do you think the following should be included?

•V/S Q4H

•Activity: Ambulate to bathroom with assistance

•Diet: Clear liquids

•An incentive spirometer is at the bedside

What medication should she be receiving? She has morphine, 5 mg IV ordered, yet you state that she received hydromorphone, 5 mg IV.

The SBAR report format was originally implemented in the U.S. Navy's nuclear submarine service as a means of quickly reporting pertinent information during a critical event. From there, the airline industry adopted it, as did others. Kaiser Permanent introduced it for use by its rapid response teams in 2002. Then, with the move to standardize communication a growing number of facilities began implementing the SBAR formation for end of shift handoff. As you can see from the example provided, it becomes clunky and unwieldy, making it a poor tool for this purpose. In my opinion, the I PASS the BATON format is much more useful for end of shift handoff.

If you haven't visited it yet, you might find the Institute for Healthcare Improvement's SBAR Toolkit helpful.

Thank you so much for the clarifications. The links you've given me are also helpful.

Where do you think the following should be included?

• V/S Q4H

• Activity: Ambulate to bathroom with assistance

• Diet: Clear liquids

• An incentive spirometer is at the bedside

I think these should all go to the assessment.

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Thank you so much for the clarifications. The links you've given me are also helpful.

Where do you think the following should be included?

• V/S Q4H

• Activity: Ambulate to bathroom with assistance

• Diet: Clear liquids

• An incentive spirometer is at the bedside

I think these should all go to the assessment.

Why do you think it should go in the assessment section, as opposed to background?

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Why do you think it should go in the assessment section, as opposed to background?

Hi Chare,

I actually moved these information to the Background prior to reading your post. Thank you!

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Do we also mention the wrong medication administered by the nurse cause in the end of the case it says nurse gave hydromorphone instead of morphine and hydromorphone is not ordered.

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