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.

Please help me write an SBAR for this case

Answer 1

#. SBAR is an acronym for Situation, Background, Assessment, Recommendation; a technique that can be used to facilitate prompt and appropriate communication.

S- T.C. is a 49-year-old woman who 3 weeks ago underwent a vaginal hysterectomy and right salpingo-oophorectomy. She has been made admit twice post surgery for treatment of infection and evacuation of hematoma . Now again she is admitted in the PACU with complaints of abdominal pain, chills, fever, and nausea and vomiting.

B - 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.

A - She is having abdominal pain of 8 out of 10 on pain scale , chills , fever ,nausea and vomiting.

R - I would recommend to have a scan of her abdomen to rule out the causative factor behind her symptoms .