VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY SBAR Instructions: Imagine you took care of __Skylar Hanson____(VSIM Scenario Patient) on clinical day one and you are at the end of your shift. You are required to provide verbal report to the next nurse who is assuming responsibility of ________(VIM Scenario Patient). Based on your VSIM experience specific to this ____________(VSIM Scenario Patient), how would you formulate a change of shift report in a SBAR format. After you formulate the SBAR, you are required to present this TOA with the rest of the clinical group in the virtual meeting. SBAR Presentation Situation: 18-year-old male admitted to the Emergency Department by his friends. PT experienced a hypoglycemic crisis and lost consciousness after his blood sugar reached 39 mg/dL Dx: Diabetes Background: - PT was diagnosed with type 1 diabetes 6 months ago. - The friends report that he started acting “weird” while they were playing basketball. He has not eaten anything for 5 hours. - Skyler told them that he felt lightheaded and was going to lie down on the cement. They became nervous and decided to bring him in to the Emergency Department. - PT was drowsy, wakes with stimulus, had slurred speech, was diaphoretic, and was acting irrationally. - Medications ordered were 50 mL of dextrose 50% in water IV slow push. IV is located in right hand. (Administered at 1540) - O2 to be greater than 92% (6L via NP was given to PT) - Venous Blood sample was taken. - Carbs and protein were given. - Vital signs to be monitored every 5 minutes & BG to be monitored PRN. - No known allergies Assessment: Current PT status: - ECG: Sinus rhythm. VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY - Heart rate: 81. - Pulse: Present. - Blood pressure: 123/73 mm Hg. - Respiration: 12. - Conscious state: Orientated x3 - SpO2: 98%. - Temp: 99 F (37 C) - There is normal skin turgor. His color is normal, and he is not sweating. - IV site: No signs of pain or discomfort. Recommendation: - Place patient in a semi-high fowlers position to promote breathing. - Continue to educate PT on his medical condition (diabetes) and the effects of hypoglycemia. - Monitor vital signs and any significant changes in BG. Inform provider if there are any abnormalities. - Monitor PT LOC and Orientation. TIME PLAN/INTERVENTIONS (STUDENT COMPLETE THIS SECTION ONLY) TO EVALUATIONS/ASSESSMENTS 1500 Arrive to unit early to go over PT charts and get prepared for the shift. Meet w/ clinical instructor to obtain info about: primary nurse, primary patient, and objectives of the day. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY* 1530 Begin the shift, visit Skylar first. Hand hygiene Introduce self Identify PT Clarify allergies Verify consent THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 1535 Collect any changes about client condition from Kardex, PT chart, change of shift report, medication from MAR. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY 1540 Perform hand hygiene, Assess neurological. Vital signs assessment (BP, PR, T, RR, PPR) General Survey Head to Toe assessment (inspect head for airway clearance) 1550 Call provider/ask instructor to call provider because something is happening to the PT. (hypoglycemic crisis and lost consciousness) THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY Review new orders. 1555 Place NP on at 6L THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 1605 Take BG. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 1610 Attach 3 lead ECG. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 1615 Obtain access to IV area and begin preparing medication with instructor. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 1620 1625 1630 1635 1640 1650 1705 1710 1715 Don gloves and admin IV medications w/ instructor supervision 1725 Have them teach back to ensure that they understand the importance. 1735 1740 1215 Don gloves and assess IV site. 1230 Attend post conference. Doff gloves and document medication Check BG Position PT in high fowlers, offer Carbs and Protein. Assess Vital Signs. Inform primary nurse about a 15 min break Return to unit and inform primary nurse. Reassess PT LOC, Vital sign, and BG. Educate primary client on diabetes and hypoglycemia. Document progress notes about Client ADL’s, nursing care, and health teaching w/ clinical instructor Don gloves and take a Venous Blood sample. Inform Primary nurse that you will be taking a break and heading to post conference w/ clinical instructor. Inform PN of the PT care that has taken place. VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY SBAR Presentation Situation: 26-year-old female police officer with paraplegia from a thoracic 8 (T8) spinal cord injury. She was transferred to the Rehabilitation unit yesterday. Background: - Spinal cord injury was caused by a low-velocity gunshot wound to her back at the T8 level while she was responding to a robbery 8 days ago. - The bullet penetrated the spinal column with no injury to visceral organs. - Last bowel movement was yesterday at 1900. - The gunshot wound appears healed. - There is no movement or sensation to the lower extremities. - She has been out of bed to a wheelchair. - Regular, high-fiber diet. - Medications ordered: Omeprazole 40 mg orally daily (0900), Enoxaparin sodium 40 mg subcutaneously (0900), Oxybutynin 5mg ex. Release orally (0900), Docusate sodium 100 mg orally every night. - No known allergies - IM cath every 4 hours. Assessment: - ECG: Sinus rhythm. - Heart rate: 90. - Pulse: Present. - Blood pressure: 126/83 mm Hg. - Respiration: 19. - Conscious state: Appropriate. VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY - SpO2: 96%. - Temp: 98 F (36.8 C) - PT cannot move her legs. There is no sensation for temperature, noxious or tactile stimulus. Reflexes are absent in both legs. There is normal elasticity of the skin. Her color is normal, and she is not sweating. Recommendation: - Perform bladder scan prior to IM cath, change every 4 hours. - Continue to educate PT on bladder management program, safety, positioning, and input/output. - Monitor input and output, the volume should be under 500 mL to prevent overdistention of the bladder. - Provide teaching and training on clean technique for intermittent catheterization. - Monitor vital signs and skin, encourage use of stockings. Your TIME PLAN Must be presented to the clinical group on VSIM day. For reference a sample Time Plan is posted on e-centennial under week 7 contents. TIME PLAN/INTERVENTIONS (STUDENT COMPLETE THIS SECTION ONLY) TO EVALUATIONS/ASSESSMENTS 0730 Arrive to unit early to go over PT charts and get prepared for the shift. Meet w/ clinical instructor to obtain info about: primary nurse, primary patient, and objectives of the day. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY* 0740 Begin the shift, visit Kim Johnson first. Hand hygiene Introduce self Identify PT Clarify allergies THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 0745 Collect any changes about client condition from Kardex, PT chart, change of shift report, medication from MAR. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 0750 Perform hand hygiene, Assess neurological. Vital signs assessment (BP, PR, T, RR, PPR) General Survey Head to Toe assessment (inspect legs) Pain assessment. VSIM SBAR AND TIME PLAN COMPLETION AND PRESENTATION TEMPLATION- STUDENT COPY 0820 Don gloves and perform bladder scan, remove gloves, and document accordingly. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 0830 Don gloves to prep IM cath. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 0840 Begin IM cath change, discard of cath. Follow appropriate hand hygiene. THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 0845 Assist w/ morning care THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 0850 Set up for breakfast THIS SECTION IS NOT REQUIRED TO BE FILLEDAPPLICABLE IN THE CLINICAL SETTING ONLY 0900 Prepare medications w/ instructor. Admin medications w/ instructor supervision. 0915 0925 1000 1015 1030 1045 Document medications accordingly. 1100 Meet with clinical instructor to discuss nursing interventions to help alleviate any PT discomfort or issues. 1115 1130 Reiterate PT education and perform nursing interventions. 1145 Document progress notes about Client ADL’s, nursing care, and health teaching w/ clinical instructor. 1200 Inform Primary nurse that you will be taking a break and heading to post conference w/ clinical instructor. Inform PN of the PT care that has taken place. 1215 1230 Come back from break and prep for post conference. Assist primary nurse w/ other patients Meet primary client and reassess for S/S and any pain. Inform primary nurse about a 15 min break Return to unit and inform primary nurse Meet with primary client to educate them on bladder management program, safety, input and output, and medications. Re-educate PT on prior teaching topics, have them teach back to ensure that they understand the importance. Attend post conference.
