Simulation I-SBAR: Chamberlain College of Nursing

I - Introduction

• Your Name: Diamond Dorsey
• Your Title: Student Nurse
• Reason for Being There: Clinical Rotation

S - Situation

• Patient: V.L.
• Age: 76 years
• Gender: Female
• Height/Weight: (Not provided)
• Allergies: NKDA (No Known Drug Allergies)
• Code Status: Full Code
• Privacy Code: (Not provided)
• Time: 2000 hours
• Attending Physician: Nikolaos Diakos, MD
• Chief Complaint: NSTEMI (Non-ST Elevation Myocardial Infarction)

B - Background

• Past Medical History:
  • Blood Transfusion
  • Breast Cancer
  • Cardiomyopathy
  • Congestive Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Coronary Artery Disease (CAD)
  • Hyperlipidemia (HLD)
  • Hypertension (HTN)
  • Mitral Regurgitation (MR)
  • Obstructive Sleep Apnea (OSA)
  • Peripheral Artery Disease (PAD)
  • Status post-bypass surgery
  • Stroke

Current Medications:

• Albuterol HFA
• Amlodipine
• Atorvastatin
• Clonidine
• Clopidogrel
• Colace
• Duo-neb
• Isosorbide Mononitrate
• Nitroglycerin
• Ranolazine
• Stiolto
• Aspirin
• Famotidine
• Lyrica

Social History: (Not provided)

A - Assessment

• Vital Signs:
  • Blood Pressure (B/P): 133/64 mmHg
  • Heart Rate (HR): 76 beats per minute
  • Respiratory Rate (RR): 26 breaths per minute
  • Temperature (TEMP): 98.1°F
  • Oxygen Saturation (SpO2): 96% on room air
  • Pain Level: 0/10
• Falls Risk: Yes
• Accu Check: Not provided
• IV Site:
  • Right Forearm
  • Right Antecubital Fossa
• IV Fluids: Normal Saline (NS)
• Isolation Precautions:
  • Contact: No
  • Airborne: No
  • Droplet: No
• Respiratory:
  • Decreased air entry bilaterally at the lung bases
  • No wheezing or crackles noted
• Cardiovascular:
  • Heart rate normal and regular
  • No murmurs, gallops, or rubs detected
• Neurological:
  • Patient is alert and oriented to person, place, and time (A&O x3)
  • No focal neurological deficits
  • Able to move all extremities without difficulty
• Gastrointestinal/Genitourinary (GI/GU):
  • Abdomen is soft, non-tender, and non-distended
  • Positive bowel sounds (BS) present in all quadrants
  • Intake and Output (I&O) being monitored
• Integumentary:
  • Skin warm to touch, with multiple blood-filled blisters noted on feet
  • A large fluid-filled blister observed on the left posterior aspect
• Psychological:
  • Patient appears awake, alert, and in no acute distress
  • Engages appropriately with the healthcare team
• Family/Support:
  • Patient is supported by her son, who is present and involved in her care
• Safety:
  • Patient education needed on bed rest and the importance of calling for assistance
  • Non-weight bearing (NWB) status emphasized to prevent falls
• Labs/Tests:
  • Abnormal Results:
    • Complete Blood Count (CBC)
    • Basic Metabolic Panel (BMP)
    • Computed Tomography (CT) of the abdomen
    • Chest X-ray (CXR)
  • Pending Results: Not specified

R - Request/Recommendation

• Monitoring:
  • Continue monitoring ventilator settings if applicable
  • Regularly assess peripheral pulses and respiratory status
• Medications:
  • Continue administration of prescribed blood thinners
• Wound Care:
  • Maintain current wound care regimen for blisters
• Hand-Off Report:
  • To be given to Professor Ufundo
  • Report provided by Diamond Dorsey, Student Nurse