Question

T.C. is a 49-year-old woman who 3 weeks ago underwent a vaginal hysterectomy and right salpingo-oophorectomy
for abdominal pain and endometriosis. Postoperatively, she experienced an intra-abdominal
hemorrhage, requiring transfusion with 3 units of packed red blood cells (RBCs). After
discharge, she continued to have abdominal pain, chills, and fever. She was readmitted twice: first for
treatment of postoperative infection and second for evacuation of a pelvic hematoma. Despite treatment,
T.C. continued to have abdominal pain, chills, fever, and nausea and vomiting.
T.C. has now been admitted to your unit from the postanesthesia care unit (PACU) after an exploratory
laparotomy. Vital signs (VS) are 130/70, 94, 16, 99.7 ° F (37.6 ° C). Respirations are shallow and her
Spo2 is 93% with oxygen at 2 L by nasal cannula. She is easily aroused and oriented to place and person.
She dozes between verbal requests. She has a low-midline abdominal dressing that is dry and intact
and a Jackson-Pratt drain that is fully compressed and contains a scant amount of bright red blood. Her
Foley to down drain has clear yellow urine. She is receiving an IV of 1000 mL D5.45NS at 100 mL/hr in her
left forearm, with no swelling or redness. T.C. is receiving IV morphine sulfate for pain control through a
patient-controlled analgesia (PCA) pump. The settings are dose 2 mg, lock-out interval 20 minutes, 4-hour
maximum dose of 30 mg. When aroused, she states that her pain is an 8 on a scale of 1 to 10. The unit is busy, and you are concerned about monitoring T.C. carefully enough. Your present patient load is six; of these, two patients are newly postoperative and one is getting ready for discharge. You have one experienced unlicensed assistive personnel (UAP) to help you. You are concerned that T.C.'s respiratory
status may further decline. Throughout the first postoperative day, it is difficult to balance T.C.'s need for pain medication and depression
of her respiratory status. The physician adjusts T.C.'s pain management regimen. By the end of the second postoperative day, her
pain is better controlled, although she is still complaining of moderate abdominal and incisional pain.
She is able to ambulate in her room with assistance, void after the Foley catheter removal, and tolerate
oral fluids without nausea. As you perform your shift assessment, you note that her abdominal dressing is
saturated with blood. You identify the need to assess T.C.'s wound.

Write a end of shift SBAR report.

Answer 1

SBAR NOTE :-

S - TC is a postoperative patient day 2 , her pain is under control , able to void self and have tolerated oral fluids . On assessment her abdominal would is saturated with blood . This is point of concern .

B - TC is a 49year old lady who underwent vaginal hysterectomy and right salphingo oophorectectomy following which she got admitted twice for infection and hematoma . She was shifted from PACU to ward and was under PCA for pain , had foleys catheter , on oxygen @2lpm by nasal prongs , NPO , on IV fluids infusion , and vital were stable.

A- On day 2 assessment ,the nurse found that her abdominal dressing is saturated with blood which was not earlier .

R- Physician should come and do a thorough assessment to find out the cause behind bleeding and management has to be done immediately before she deteriorates.