NUR 646 SBAR Patient Encounter Form
NUR 646 SBAR Patient Encounter Form
SBAR Patient Encounter Form
| Clinical Experience Date: ___________ | |
| Total Clinical Hours Completed to Date | 30 hours
|
| Description of Observations and Tasks During the Clinical Experience | Throughout this rotation, I witnessed thorough patient evaluations, participated in medication reconciliation, and collaborated on interdisciplinary rounds. I conducted record checks, monitored vital signs, provided patient education, and supervised the administration of nebulized medications and oxygen therapy. I contributed to documenting progress notes and practiced applying SBAR communication in team meetings. |
| Learner Reflection on Clinical Experience | This professional experience enhanced my understanding of managing chronic conditions in a diverse patient population, including geriatric patients, particularly those with respiratory issues. I acquired the skills to customize teaching to facilitate self-care for patients with respiratory and cardiovascular illnesses, as well as other chronic diseases affecting various bodily systems. Collaboration with the care team underscored the significance of effective communication and prompt intervention. I possess greater confidence in exercising my judgment, incorporating evidence-based solutions, and treating patients’ physical and emotional needs comprehensively. |
| SBAR | |
| Situation (The exact circumstances of the problem are explained.) | Mr. D., a 78-year-old male with a history of COPD and hypertension, was evaluated for escalating shortness of breath, exhaustion, and wheezing unresponsive to home inhalers. The patient indicated challenges in performing everyday activities and an exacerbation of a productive cough over the last three days. Upon arrival, he exhibited anxiety, with an oxygen saturation of 88% on room air, a respiratory rate of 26 breaths per minute, and bilateral wheezing. He was conscious but employing auxiliary muscles for respiration. The objective of the meeting was to assess symptom exacerbation and establish subsequent actions for acute care and symptom management (Kovacs et al., 2022). |
| Background (Presents essential information related to the situation. This information should pertain only to the current patient situation.) | Mr. D. has a 20-year history of chronic obstructive pulmonary disease and has been diagnosed with hypertension for more than 10 years. He resides autonomously and uses supplementary oxygen at night. His most recent hospitalization for a COPD exacerbation took place six months ago. He adheres to his pharmaceutical regimen, which comprises tiotropium, albuterol, lisinopril, and hydrochlorothiazide. His recent exacerbation of respiratory symptoms occurred after exposure to smoke from a proximate wildfire. He has no documented medication allergies. The most recent spirometry indicated moderate obstructive pulmonary disease. His vital signs are stable, except for high blood pressure (148/94 mmHg) and increased respiratory effort (Mollica et al., 2020). |
| Assessment (Objective statements based on the situation and background information.) | Mr. D. is undergoing an acute exacerbation of COPD, probably induced by environmental irritants. Clinical observations include heightened dyspnea, a productive cough, decreased oxygen saturation, bilateral expiratory wheezes, and the use of accessory muscles. Lung auscultation indicates widespread wheezing, with the absence of crackles, and peripheral edema is not present. He is hemodynamically stable but susceptible to rapid decompensation without timely intervention. His hypertension is persistently raised but is not in crisis at present. No indications of pneumonia or fluid overload were detected. Additional diagnostic evaluations, including a chest X-ray and arterial blood gas analysis, are necessary to ascertain the severity of the exacerbation (Kahnert et al., 2023). |
| Recommendation (Include a recommendation for resolving the issue based on the situation, background, and assessment.) | I suggest initiating nebulized bronchodilator therapy (albuterol/ipratropium), administering systemic corticosteroids, and providing supplemental oxygen to maintain oxygen saturation above 90%. Closely observe vital signs and breathing effort (Polman et al., 2024). A chest X-ray is necessary to rule out pneumonia or other conditions. Considering the patient’s medical history and risk factors, it is advisable to admit him for monitoring and continuous respiratory therapy (Mariniello et al., 2024). Promote the ongoing utilization of prescribed home treatments and emphasize proper inhaler technique. It is recommended to conduct a follow-up with the pulmonary and primary care teams. If no improvement is observed within a few hours, escalation to BiPAP or transfer to the intensive care unit (ICU) may be required. |
| Educational Plan: (Include a suggestion for an educational plan to address one aspect of the patient’s care. Include recommendations based on evidence-based guidelines/research related to a specific patient finding. | An evidence-based educational approach must emphasize the reinforcement of proper inhaler technique, adherence to medication, and the identification of early signs and symptoms of COPD exacerbation. Mr. D. should get guidance on avoiding environmental triggers, specifically smoke and allergies, and be provided with smoking cessation tools if relevant. The GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines suggest that action plans for COPD self-management improve outcomes (Mollica et al., 2020). He should be motivated to participate in pulmonary rehabilitation and maintain adequate hydration and nutrition. Instruction should be supplemented with written guidelines and teach-back techniques to guarantee comprehension. |
References
Kahnert, K., Jörres, R. A., Behr, J., & Welte, T. (2023). The diagnosis and treatment of COPD and its comorbidities. PubMed, 120(25), 434–444. https://doi.org/10.3238/arztebl.m2023.027
Kovacs, G., Avian, A., Bachmaier, G., Troester, N., Tornyos, A., Douschan, P., Foris, V., Sassmann, T., Zeder, K., Lindenmann, J., Brcic, L., Fuchsjaeger, M., Agusti, A., & Olschewski, H. (2022). Severe pulmonary hypertension in COPD. CHEST Journal, 162(1), 202–212. https://doi.org/10.1016/j.chest.2022.01.031
Mariniello, D. F., D’Agnano, V., Cennamo, D., Conte, S., Quarcio, G., Notizia, L., Pagliaro, R., Schiattarella, A., Salvi, R., Bianco, A., & Perrotta, F. (2024). Comorbidities in COPD: current and future treatment challenges. Journal of Clinical Medicine, 13(3), 743. https://doi.org/10.3390/jcm13030743
Mollica, M., Aronne, L., Paoli, G., Flora, M., Mazzeo, G., Tartaglione, S., Polito, R., Tranfa, C., Ceparano, M., Komici, K., Mazzarella, G., & Iadevaia, C. (2020). Elderly with COPD: comorbidities and systemic consequences. Journal of Gerontology and Geriatrics, 69(1), 32–44. https://doi.org/10.36150/2499-6564-434
Polman, R., Hurst, J. R., Uysal, O. F., Mandal, S., Linz, D., & Simons, S. (2024). Cardiovascular disease and risk in COPD: a state-of-the-art review. Expert Review of Cardiovascular Therapy, 22(4–5), 177–191. https://doi.org/10.1080/14779072.2024.2333786
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Assessment Description
Complete the “SBAR Patient Encounter Form” to document your total clinical hours completed to date, a description of observations and tasking completed, and additional comments regarding your reflection on your clinical patient experience. You will also complete the SBAR section of the form related to a patient you have assessed during your clinical experience thus far.