Mr Boyd Case Study

SBAR sample with nurse in clinical

Situation:

I went into the room to check on patient and she reported she has fallen out of bed and would like you to come and check her right leg, which she states “feels as if it is not working as well as usual”.

Background:

When I entered the room, the patient was rubbing her right leg. She reported she had fallen out of bed on the night shift, she believes around 3:00 am. She got herself back into bed and did not tell the night nurse of the fall. It did not bother her as much at the time but it is now feeling more painful.

Assessment:

I looked at the right leg and it is swollen and bruised. She is splinting it when she moves and looks in pain. I completed a pain assessment and she reports the pain as the following:

P: provoked by movement, has not allowed her to fall back asleep

Q: Throbbing, feels like it is swelling

R: It is located on right thigh and is radiating up and down her leg at this time

S: She rates it as 5 out of 10

T: It starting after the fall and has been constant and has gotten worse throughout the night.

Her vital signs were:

B/P=170/92 T=97.2 Pulse Ox=96

P=94 R=20

Recommendation:

If you could please come and look at her leg, and let me know if there is anything, I need to do in the meantime.