Patient Care SBAR Communication Tool
Mrs. Marg Simpson
DOB 20/01/1955
Hospital ID 32567211
MRP Dr. Dobbs
Situation
Background
Assessment
Recommendations
DOA: yesterday 0600
Reason for admission:
Laparotomy for Radical
Hysterectomy secondary to
fibroids and bleeding.
Medical/Surgical History:
No allergies.
Uterine prolapse for 5 years.
Hypertension
Bipolar disorder (weaned off lithium
over concerns of renal damage)
VS:
Today 0800
38.9 C
66
21
144/100
94% on 2LPM prongs.
Assessments:
VS: q1h x 4 hrs. Then routine.
Safety:
All bed rails up.
Spiritual practices: Orthodox Jewish
Diet: Clear fluids when bowel sounds
return.
Mobility: as tolerated.
Language: English
Labs: this morning
HGB: 126 mg/dl
Na: 135 mmol/L
K: 4.5 mmol/L
Diagnostics:
Ultrasound indicated location
of uterus and uterine ligaments
preoperatively
Assistive devices:
Next of kin:
Sub. Decision maker:
Social work:
Skin integrity:
PT/OT:
Oxygenation:
Elimination: In and out catheter if post
void greater than 250 ml.
Post op day 2
Labs: Repeat CBC, Lytes at 1600
Diagnostics: Bladder scan post void
once catheter removed. In and out
catheter if residual is greater than 250
mL. Send specimen for C and S.
IV: Normal Saline 125 ml/h
Saline lock when drinking greater than
2000 mL/ 24 h.
Mrs. Marg Simpson
Patient Care SBAR Communication Tool
DOB 20/01/1955
Hospital ID 32567211
MRP Dr. Dobbs
Work with your assigned partner.
It is now post op day 2: You admitted the client yesterday from PACU.
Report from night nurse stated no concerns. She had her IV Abx as ordered and the foley was removed at 2200.
You begin care for this client at 0700. During your assessment you noted that she had not voided since 2200. You offer her to use the
female urinal and she voids 100 ml of cloudy dark amber urine. She complains that it is hard to push the urine out.
You follow orders and do a post void bladder scan. Residual urine volume is 300 ml. Proceed with ordered care. Provide a DAR note
posted online for evidence of completion and a pre lab mark.