WORKSHEET FOR SBAR ASSIGNMENT POST SIMULATION
SBAR Nurse to Nurse Report Worksheet
Patient Name: Jill Johnson Allergies: KNA
Code Status: { FULL } DNR PALLIATIVE
S (Situation) Ms. Johnson is complaining of having no energy
has became increasingly withdrawn, and has a plan for self
harm.
Diagnosis: No prior diagnosis noted
B (Background) Ms. Johnsn is a second semester student was
brought down to the student clinic to be evaluated on here recent
change in behavior. Her sister Joyce stated that Jill has stopped
eating has loss weight, and has been missing classes. Jill has
stated that she is tired and can’t go on with her day to day
activities. Patient has a plan to harm one’s self. A no Suicide
contract has been signed between the patient and I.
Past Medical History: Patient has no prior medical
history.
A (Assessment)
Vital Signs: Temp: 97.6 HR: 82 B/P: 115/70 RR: 20 02 sat % :
100% on: room air
Neuro: A & O x 3 , Eyes PEERLA, conjunctiva normal
Cardiac: Auscultated heart S1 and S2 present no heart murmurs
noted.
Respiratory: lungs clear bilaterally
Gastrointestinal: Positive bowel sound in all four quadrants.
Last BM this morning 04/18/2020. Formed stool noted. No abdominal
pain.
Genitourinary: Patient continent no complaints of abdominal
pain or discomfort noted.
Extremities: Active range of motion to all extremities.
Strength egual bilaterally. No edema
Ms Johnson reports that she is overwhelmed with stress and
does not have any social support here at school. She shows signs of
hopelessness, loss of interest, lack of concentration, slowness in
activity, and thoughts of suicide. WHODAS scale was completed her
score was 126/36 was calculated as 4.84 rating of severe to extreme
disability.
R (Recommendations) My recommendation is that my patient
should be seen by physician and referred to Psychiatry to discuss
what is causing her change in behavior and suicidal thoughts.