Choose an experience from your nursing practice. Using the “SBAR” template, explain the situation in detail, followed with background information. Then explain your immediate assessment and recommendations you have for the provider. Include the following in the “SBAR” template: This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
SBAR Template:
Situation:
I would like to discuss an experience that I encountered during my nursing practice involving a patient with a suspected case of sepsis. The patient was a 65-year-old male with a medical history of diabetes mellitus type 2 and chronic obstructive pulmonary disease (COPD). He presented to the emergency department with symptoms of fever, altered mental status, and labored breathing. I immediately initiated the SBAR communication method to effectively communicate the situation to the healthcare provider.
Background:
The patient’s vital signs upon arrival were as follows: temperature of 39.2°C, heart rate of 110 beats per minute, respiratory rate of 26 breaths per minute, blood pressure of 140/90 mmHg, and oxygen saturation of 90% on room air. The patient appeared lethargic and was not able to provide a clear medical history or present symptoms effectively. The patient’s medical history revealed a prolonged use of corticosteroids for his COPD, which could potentially suppress his immune system, increasing the risk of infection.
Immediate Assessment:
Based on the patient’s symptoms and vital signs, it is crucial to consider sepsis as a potential diagnosis. Sepsis is a life-threatening condition caused by a systemic response to infection. The patient’s fever, altered mental status, and labored breathing are consistent with the clinical presentation of sepsis. Additionally, his vital signs indicate signs of physiological stress, such as tachycardia and tachypnea. The low oxygen saturation suggests inadequate gas exchange, possibly due to respiratory compromise.
Recommendations for the Provider:
1. Initiate appropriate resuscitation measures: Given the patient’s clinical presentation and vital signs, it is crucial to initiate prompt and appropriate resuscitation measures. This should include providing supplemental oxygen via a non-rebreather mask to improve oxygenation and optimizing the patient’s perfusion by administering intravenous fluids, such as isotonic crystalloids.
2. Broad-spectrum antibiotic therapy: Given the suspected infection leading to sepsis, it is essential to initiate broad-spectrum antibiotic therapy as soon as possible. This will help cover a wide range of potential pathogens and prevent further progression of the infection. Ideally, blood and other appropriate cultures should also be obtained before initiating antibiotics to identify the causative organism(s).
3. Hemodynamic monitoring: Continuous monitoring of the patient’s hemodynamic status is crucial in managing sepsis. This includes measuring central venous pressure (CVP), arterial blood pressure, and cardiac output. This information will help guide fluid resuscitation and vasopressor support if necessary.
4. Source control: Identifying and controlling the source of infection is essential in managing sepsis. This may involve obtaining appropriate cultures, performing imaging studies (e.g., chest X-ray), and consulting with other specialists as needed (e.g., infectious disease physician, pulmonologist).
5. Involve the interdisciplinary team: Given the complexity of sepsis management, it is essential to involve the interdisciplinary team, including respiratory therapy, pharmacy, and infectious disease specialists. Their expertise and input can contribute to the formulation of an effective treatment plan and facilitate smooth patient care transitions.
In conclusion, this SBAR communication describes a situation involving a patient with suspected sepsis. The immediate assessment indicates the need for prompt resuscitation measures, initiation of broad-spectrum antibiotic therapy, hemodynamic monitoring, source control, and involvement of the interdisciplinary team. The effective use of the SBAR communication tool ensures clear and concise communication, enabling efficient management and collaboration among healthcare providers.