SBAR

Situation

With regards to the Nursing Education Program of Saskatchewan course 300.3 entitled Health Challenges Theory III, our clinical group is required to complete a critical reflective assignment. Throughout this assignment we will demonstrate our ability to apply theoretical concepts learned in class to practical settings of managing a complex patient. The patient involved with this assignment, John Rambo, was admitted to RUH 6000 Cardiosciences and was cared for by a 3rd year nursing student. Acute Coronary Syndrome was his admitting diagnoses with periods of unstable angina. Following this brief SBAR guideline, there is an in depth analysis of John Rambo utilizing a preparation guide, assessment guide, care plan, and web links.

Background

John Rambo was admitted to the Emergency Department at RUH on February 3rd 2009 with complaints of retrosternal chest pain. This ‘sharp’ chest pain was relieved either solely by nitro-glycerine or in combination with morphine. In addition to morphine and nitro-glycerine, John Rambo is on a variety of other medications including Metoprolol, Sertraline, and Nitroglycerine. He has no known allergies, is currently DNR, and has heparin running via IV. In addition, palliative care has been discussed with the patient and will be the course of action from this day forward. His most recent vital signs were temperature 37.5 degrees Celsius, pulse 88, respiration rate 14, BP 120/80, and oxygen saturation at 92% on room air. Abnormal lab results for Mr. John Rambo include MCH, Lymphocyte, Urea, Creatinine, APTT, RBC, Hematocrit, & Hemoglobin which are further evaluted within the clinical prep guide below.

Assessment

In order to provide high quality care to John Rambo, it is necessary to perform a holistic assessment. Areas of focus include:

Subjective Data

• Inquire about any pain or discomfort including chest pain, palpitations, shortness of breath, cough, fatigue, nausea/vomiting, dizziness, lightheaded, any swelling John has noticed
• Assess family history by noting the ages and health status of the patient’s family members. Pay close attention to a family history of CAD, MI, sudden death, hypertension, hyperlipidemia, hypercholesterolemia, or diabetes
• Focused chest pain assessment:
• P- Provokes, palliates, precipitating factors What provoked the pain? What makes the pain better? What makes the pain worse? Have you had this type of pain before? What were you doing when the pain occurred?
• Q- Quality What does the pain feel like? Is it burning? Crushing? Tearing? Sharp?
• R- Region, radiation Show me where the pain is. How large an area is involved? Does the pain radiate? If so, where?
• S- Severity, associated symptoms How severe is the pain? If you were to rate the pain on a scale from 0 to 10, with 10 being the most sever pain you can imagine how would you rate your pain? What else did you feel besides the pain?
• T- Time, temporal relations When did the pain start? How long did it last? Does it come and go? Were you awakened by the pain? Is the pain always present?
  
• Emotional & Cognitive Assessment
• Assess appearance, behaviour, mood, affect, cognitive functioning, thought process, perceptions, and perform a mini-mental status examination
  
• Social Assessment
• Include assessment of roles, family relationships, work relationships, social relationships, & sexuality

Objective Data

• Head
• Inspect and palpate for clean hair, sores (possibly from anti-coagulation medications), bruises
• Inspect face for symmetry by having patient smile and frown (CN 7) Palpate temporal artery and TMJ joint Inspect eyebrows
• Eyes: eyeglasses, tearing, color of iris
• Get patient to follow finger to observe vision (CN 3,4, 6)
• Ears Symmetrical, skin condition, move auricle and push tragus for assessment for tenderness
• Nose: inquire about allergies, bloody nose, discharge Test patency of each nostril
• Mouth: inspect mucosa, teeth, tongue, floor and uvula
• Have patient stick out tongue (CN 12)
• Ask patient to shrug shoulders and press against shoulders to test CN 11 which is an indicator of lung expansion
• Neck
• Inspect neck for symmetry, lumps, and pulsations
• Palpate cervical lymph nodes
• Inspect and palpate carotid pulse one side at a time, then listen for carotid bruits
• Palpate trachea in midline Check JVP
• Respiratory System Inspect posterior chest: thoracic cage, skin, symmetry, muscle use
• Palpate for symmetric expansion, tactile fremitus, lumps, or tenderness
• Percuss over all lung fields and diaphragmatic excursion
• Percuss costovertebral angle
• Auscultate breath sounds
• Then switch to ANTERIOR CHEST and repeat previous posterior assessment
• Cardiovascular
• Inspect Anterior chest and note any heaves, thrills, or pulsations (ex. apical pulse)
• Palpate apical impulse and precordium if I have not already done so
• Palpate precordium
• Have patient sit up and auscultate heart with diaphragm and bell
• Turn person over to left side while again auscultating apex with the bell
• Then have patient sit up, lean forward and exhale while you listen with the diaphragm at the base, right, and left sides for a diastolic murmur or aortic/pulmonic regurgitation
• Upper Extremeties:
• Palpate axilla and regional nodes
• Pulses: brachial, radial (looking for rate, rhythm, force) Check fingers and ask patient to squeeze your hands
• Abdomen
• Look for incisions, bruising, distension, aorta pulsation
• Listen for Bowel sounds/arteries, palpate, & percuss
• Ask about last bowel movement and last void Palpate femoral pulse and inguinal nodes
• Lower extremities
• Inspect for symmetry, skin, and hair distribution
• Palpate pulses: popliteal, posterior tibial, dorsalis pedis
• Palpate for temperature, and edema
• Separate toes and inspect (important since John Rambo is diabetic and may develop ulcers & neuropathy)
• Ask patient to push feet down and up against your hand Ask if they have any pain in their legs

Laboratory Studies

• Examine cardiac markers including CK, troponin, & myoglobin to evaluate cardiac status and possible acute myocardial events

Radiology & Imaging ·

• Portable chest x-ray is a non-invasive tool used to visualize the heart ·
• Echocardiography used to visualize and asses cardiac function, structure, and hemodynamic abnormalities ·
• Abdominal ultrasound to examine John Rambo’s kidney function ·
• Electrocardiogram which examines electrical activity of the heart
  

Recommendation

• Upon reflection of John Rambo’s current health goals and status, we recommend that the primary focus of nursing care be aimed at providing pain relief- primarily focusing on chest pain. After discussing health care options with the patient, palliative care was decided as an appropriate route and as a result, palliative employees will now be integrated into John’s health care team. Patient teaching is another vital component in his health care, since it will provide John with the tools and resources he needs to live independently in his Saskatoon condo. Overall, medical tests, diagnostic reports, and long hospital stays are no longer appropriate interventions for John Rambo, but rather comfort, psychological health, and a maintained lifestyle are the primary goals of care.