Comprehensive Nursing Study Guide: SBAR and Medication Administration Case Study

SBAR Background and Patient Context

• The background component of an SBAR (Situation, Background, Assessment, Recommendation) provides specific details to the receiver, such as a physician or nursing instructor, to facilitate understanding of the patient's current status.

• Key elements to include in the background are:

  • Admitting diagnosis.

  • Medical history.

  • Allergies.

  • Current medications.

  • Any other remarkable findings or details.

• Background information is particularly vital for physicians who manage many patients or for those covering for a colleague, as they may not have detailed recall of every individual case.

Case Study: Arty Rhythm

• Goals of Care: M2.

• Admitting Diagnosis: Acute pulmonary edema and congestive heart failure (CHF).

• Medical History:

  • Hypertension.

  • Hyperlipidemia.

  • Peripheral artery disease (PAD).

• Allergies:

  • No known drug allergies (NKDA).

  • Food allergies: Avocado and peppers.

• Current Vital Signs:

  • Pulse: $98\,\text{bpm}$ (radial).

  • Blood Pressure: $84/52\,\text{mmHg}$.

  • Respirations: $20\,\text{breaths/min}$.

  • $SpO_2$: $94\%$ on $2\,\text{liters}$ via nasal prongs.

  • Temperature: $36.8^\circ\text{C}$ (tympanic).

Medication List and Administration Details

• Acetaminophen: $500\,\text{mg}$ PO (oral) every 4 hours PRN (as needed) for mild pain or fever.

• Atorvastatin: $40\,\text{mg}$ PO daily.

• Clopidogrel: $75\,\text{mg}$ PO daily.

• Furosemide: $40\,\text{mg}$ PO daily.

• Lisinopril: $20\,\text{mg}$ PO daily.

• Nitroglycerin spray: $0.4\,\text{mg}$ sublingual PRN for chest pain.

• Sennosides: 2 tabs oral once daily at bedtime PRN.

Clinical Assessment for Medication Administration

• Antiplatelet Assessment (Clopidogrel):

  • When administering an antiplatelet like Clopidogrel, the nurse must monitor for signs of bleeding.

  • Laboratory monitoring includes the coagulation profile: PT (Prothrombin Time), INR (International Normalized Ratio), and APTT (Activated Partial Thromboplastin Time).

  • For patient Arty Rhythm, PT, INR, and APTT are within normal limits (WNL).

  • Physical assessment for bleeding involves checking stools; Arty's stools are currently noted as type 4 and type 3 on the Bristol Stool Scale with no signs of blood.

  • Nurses' notes should be reviewed for clinical indicators of bleeding, such as:

    • Epistaxis (nosebleeds).

    • Bleeding gums.

    • Hematochezia or melena (dark tarry stools).

    • Ecchymosis (bruising).

• Recommendation for Clopidogrel: Based on normal lab values and the absence of clinical signs of bleeding, the recommendation is to proceed with the administration of Clopidogrel.

• Clinical Judgment for Other Medications:

  • The patient is significantly hypotensive, with a blood pressure of $84/52\,\text{mmHg}$.

  • Lisinopril (Antihypertensive): Should be held due to the patient's low blood pressure.

  • Furosemide (Loop Diuretic): Should be held in the context of this assessment.

Guidelines for Clinical Documentation and Review

• Data Selection: When reviewing the chart for SBAR preparation, use the most recent data available. If today's values are recorded, use those; if not, use the most recent values from yesterday.

• Reviewing the Chart: Students should spend adequate time (approximately 25 minutes is provided for the full chart review) examining the nurse's notes, as this is a common area where relevant information regarding drug classifications is missed.

• SBAR Presentation: Students may read directly from the chart for the background section rather than writing everything out, provided they state the necessary components (goals of care, diagnosis, meds) clearly.

• Focusing the Assessment: The SBAR assessment should prioritize information directly relevant to the specific drug classification being discussed. While general findings (like hypotension) can be noted, the primary focus must stay on the criteria for the specific medication at hand.

Questions & Discussion

• Question (Carrie): Should the data be based on yesterday's date or today's date and time?

• Response (Instructor): You should look at today's date or the most recent value available. If today's is there, use it. If the most recent is from yesterday, use that.

• Question (Carrie): For documentation, do we read all of the notes or what?

• Response (Instructor): Yes, read all of them. The chart is quite long but similar across different patients, differing mainly by medication classifications such as anticoagulants, cardiac glycosides, osmotics, laxatives, or beta blockers. Pay close attention to the nurse's notes for classification-relevant data.