case study

Guidelines for Communicating with Physicians Using the SBAR Process

1. Use the following modalities according to physician preference, if known. Wait no

longer than five minutes between attempts. 1. Direct page (if known) 2. Physician’s Call Service 3. During weekdays, the physician’s office directly 4. On weekends and after hours during the week, physician’s home phone 5. Cell phone

Before assuming that the physician you are attempting to reach is not responding, utilize all modalities. For emergent situations, use appropriate resident service as needed to ensure safe patient care.

2. Prior to calling the physician, follow these steps:

• Have I seen and assessed the patient myself before calling? • Has the situation been discussed with resource nurse or preceptor? • Review the chart for appropriate physician to call. • Know the admitting diagnosis and date of admission. • Have I read the most recent MD progress notes and notes from the nurse who

worked the shift ahead of me? • Have available the following when speaking with the physician:

• Patient’s chart • List of current medications, allergies, IV fluids, and labs • Most recent vital signs • Reporting lab results: provide the date and time test was done and results of

previous tests for comparison • Code status

3. When calling the physician, follow the SBAR process: (S) Situation: What is the situation you are calling about?

• Identify self, unit, patient, room number. • Briefly state the problem, what is it, when it happened or started, and how severe.

(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

This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials in the spirit of patient safety, and please retain this footer in the spirit of appropriate recognition.

DRAFT 5/7/03

(A) Assessment: What is the nurse’s assessment of the situation?

(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

4. Document the change in the patient’s condition and physician notification. This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials in the spirit of patient safety, and please retain this footer in the spirit of appropriate recognition.

Student example

General status, vital signs and pain: Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions

Findings

Current Status

1. Allergies No Known Drug Allergies

2. Present health concerns

Vocalizes concern about hypercholesterolemia. Denies other health concerns.

Past History

3. Recent weight gains or losses?

NA

4. Previous high fevers, cause, and treatment?

Denies any recent fevers.

5. History of abnormal pulse?

none

6. History of abnormal respiratory rate or character?

Denies history of respiratory illness.

7. Usual blood pressure, who checked it last, and when?

Usual blood pressure is described by patient as normal. Checked last month at doctor’s office, reading: 100/76.

8. History of pain and treatment?

Complains of arthritis in hands. (States rheumatoid arthritis runs in the family)

Family History

9. Hypertension? Denies family history of hypertension.

10. M Metabolic/growth problems?

Denies family history of metabolic or growth problems.

Pain (Everyone has had pain at some time or other-if your patient is healthy and currently pain-free, you may need to use a past instance of pain.)

11. P Pain (using COLDSPA) Character: how does it feel—what sort of pain is it?

Aching sensation in hands bilaterally.

About 10 years ago

Commented [D1]: Note that examples may not be exactly like your assignment-this form is used in several classes and differs from class to class.

Commented [D2]: -1 pt. NA not appropriate for this class. Could have used “Denies weight gain or loss in last year.”

Commented [D3]: -1 pt. “Denies abnormal pulse” would have been OK—“none” not appropriate for this class.

Commented [D4]: This is OK because it is using the patient’s own words—no point off for this. It goes on to describe what the patient considers “normal”.

Commented [D5]: The form asks for history, which this assessment partner has—we need how long and what treatment here. -1 pt.

12. Onset:

13. Location:

Base of both thumbs and in her fingers—symmetrical pain, sometimes extending to finger joints as well.

14. Duration:

Mild constant underlying pain which does seem to vary depending on the weather.

15. Severity (scale of 1 – 10):

2 - 3

16. Pattern—what makes it better or worse:

NSAIDs help temporarily, specifically Advil. She takes a dose 2 – 3 times per week as directed on the bottle. (She reports taking either 3 or 4 200 mg. tablets in a dose, depending on how uncomfortable she is.)

17. Associated factors— does it cause you to have other symptoms too?

Weather affect it, cold weather make it worse.

18. How does pain impact the other areas of life?

2.What are your concerns about the pain’s effect on

a. general activity? Denies effect

b. mood/emotions? Makes pt feel old

c. concentration? Denies effects

d. physical ability? Denies effects

e. work? Denies effects

f. relations with other people? Initially denies effects, though admits that she is more irritable and impatient with others.

g. sleep? Denies effects

h. appetite? Denies effects

i. enjoyment of life? States that it does decrease her

Commented [D6]: Could have been more specific— “constant” does describe duration to some extent…OK, no points deducted.

Commented [D7]: This information belongs under # 16, above. Associated factors might be something like: When she has arthritis pain, she feels irritable and depressed and eats more. She feels more tense and this causes her to have headaches….etc. = -1pt. In the box, the student makes grammatical errors=-2pts.

quality of life, though not significantly.

19. Exercise, how much, what sort?: How many times per week does assessment partner get 30 minutes of moderate exercise?

Usually twice a week she goes for a 30-minute walk in her neighborhood.

Nutritional assessment: Subjective data

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions

Findings

Current Status

1. Type of diet (for instance, low carb, vegetarian, diabetic)

Vegetarian

2. Appetite changes Denies recent appetite changes

3. Weight changes in last 6 months?

Denies weight changes in the last 6 months

4. Problems with indigestion, heartburn, bloating, gas?

Complains of rare instances of heartburn.

5. Constipation or diarrhea?

Denies recent constipation or diarrhea.

6. Dental problems? Received partial crown 6 months ago. Denies other dental problems.

7. Conditions/diseases affecting intake or absorption, i.e., irritable bowel disease, gluten sensitivities, etc.,?

Denies any GI sign or symptoms.

8. Frequency of dieting?

Denies recent dieting.

Family History

9. Chronic diseases? Denies family history of chronic diseases.

10. Weight issues? Denies family history of weight issues.

Lifestyle and Health Practices

19. Average daily food intake—how many meals and snacks?

2 meals per day and 1 - 2 snacks per day.

20. Approximately how many 8-oz. glasses of fluid per day are consumed?

9 - 13 8-oz. glasses of liquid are consumed daily.

21. Type of beverages consumed?

8 - 10 glasses of water, 1 - 2 cups of coffee, occasionally 1 cup of tea is consumes daily.

22. Dine alone or with others?

half the time alone, half the time with family members

23. Frequency of eating out?

1 - 2 times per week

24. Do long work hours affect diet?

Pt puts off eating if busy

25. Sufficient income for food?

yes

26. 24-hour dietary recall (The assessment partner will only need to recall the items eaten and general amount—we cannot require more specificity here since most people will not remember it any greater detail.)

Breakfast: 2 cups coffee with cream Fruit smoothie--2 cups Scrambled eggs, 2 Lunch--skipped and had a Kind nut bar. Supper: Lasagna--medium serving large salad with Italian dressing a handful of walnuts chocolate-about a 2 inch by 2 inch portion. Snack (a couple of hours after supper): more chocolate--the rest of the large bar, probably twice as much of it as was eaten at supper.

27. How many alcoholic drinks per week are

Usually has 1 - 2 drinks (wine or beer) about 3 times per week.

consumed?

Objective data: General status and vital signs

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, used with permission.

Questions

Findings

Current Status

1. Observe physical development (i.e., appears to be chronologic age) and sexual development (i.e., appropriate for gender and age).

Physical and sexual development appears appropriate for age and gender.

2. Observe skin (i.e., general overall color, color variation, and condition).

Overall skin condition is healthy and the color is appropriate for ethnicity. Light brown macules present to backs of hands. Skin turgor elastic—skin a little loose on back of hands, but appropriate for age and appearance. Temperature, and dryness appear appropriate.

3. Observe dress (occasion and weather appropriate).

Dress is appropriate for occasion and weather.

4. Observe hygiene (cleanliness, odor, grooming).

Appears clean and well groomed, no odor detected.

5. Observe posture (i.e., erect and comfortable) and gait (i.e.,rhythmic and coordinated).

Posture erect and gait coordinated

6. Observe general body build (muscle mass and fat distribution).

General body build appears appropriate for age and gender

7. Observe consciousness level (alertness, orientation, appropriateness).

Awake, alert and oriented to person, place, and time

Commented [D8]: Great use of terminology here! We haven’t even covered skin lesions specifically—we will in the next module—Great job!

8. Observe comfort level-does patient exhibit visible signs of pain?

No visible signs of pain

9. Observe behavior (body movements, affect, cooperativeness, purposefulness, and appropriateness).

Behavior purposeful and appropriate

10. Observe facial expression (culture- appropriate eye contact and facial expression).

Facial expressions and manner appropriate

11. Observe speech (pattern and style).

Speech pattern regular and even

Vital Signs

12. Temperature (document route) 98.3

13. Heart rate (pulse-- rhythm, amplitude)

(Document units—beats per minute)

73

14. Respirations (rate, rhythm, and depth).

(Document units—breaths per minute)

16

15. Blood pressure 110/62

Objective data: Nutrition assessment

Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with permission.

Questions

Findings

Current Status

1. Measure height. 5’6”

Commented [D9]: -1 pt. Route not documented

Commented [D10]: -1 pt. Units not documented— beats/min.

Commented [D11]: -1 pt. Units not documented— breaths/min

2. Measure weight (1 kg = 2.205 lb). 139 lbs

3. Determine BODY MASS INDEX (BMI = weight in kilograms/height in meters squared or use the NIH website: http//nhlbisupport.com/bmi/bmicalc.htm). Compare results to BMI in Table 13-3, on in the textbook.

22.4 Within normal range

4. Measure waist circumference and compare findings to Table 13-5 in the textbook.

33 inches No increased risk for Type 2 Diabetes, hypertension, or cardiovascular disease

SBAR

Read the instructions and rubric on the assignment form before completing this. As you

have assessed your patient, which finding from the “General Status, Pain, Nutrition and Vital

Signs” assessment would require attention from the clinician (if it is sufficiently serious to

warrant medical attention) or from you as a nurse if it regards a health promotional/lifestyle

problem? Select a problem you feel to be of importance and address it using the SBAR form. If

you have a healthy assessment partner, it may be as simple as addressing that he/she gets

insufficient exercise or doesn’t eat a balanced diet—perhaps not as many fruits or veggies as

recommended. Most people don’t drink enough water—you can often use that if nothing more

serious is apparent. If your assessment partner has chronic health problems or pain, address

one of those problems below.

SBAR

Situation Jane Doe reports constant pain in her hands today—scores the pain as 2 – 3 out of 10.

Background She is a 50-year old in good health and reports no other chronic conditions. Mild constant hand pain which varies with weather, is temporarily relieved with ibuprofen. Patient has had this pain for 10 years and has a family history of rheumatoid arthritis. She has used Advil with effective short-term relief for the last 2 – 3 years.

Assessment

(Name the problem)

She has signs and symptoms pointing toward mild rheumatoid arthritis.

Recommendation Continue to use over-the-counter analgesics as directed on bottle as she has been doing, and mention it to her clinician at the next health care visit so it can become a part of her recorded health history. Also, her clinician may suggest a better treatment.

Commented [D12]: This assessment partner reveals no acute health problems and very little to write an SBAR with—her arthritis will work for this purpose. We could also use her nutrition assessment—on the day she recalled her food intake, she had only 1 vegetable. In the chapter on Nutrition, the current recommendations show that about 25% or more of the intake should consist of vegetables. Your textbook recommends 2000 to 3000 ml of fluid per day. This person gets that much, so we couldn’t use liquid intake as a wellness or “health promotional” SBAR, as you could for a lot of the population.

Commented [D13]: The SBAR is on a low-priority assessment finding, but given that the patient is healthy and has no urgent serious complaints, this is a good choice. The SBAR is written correctly and should receive full points. Outpatients may use OTC (over the counter) meds, following the instructions if there are no contraindications.

Total score for this student—91% A score range of 89 – 93% would be acceptable—always remember

that some graders will see more strengths and weaknesses than others and +2% or -2% is an acceptable

range.