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INTRODUCTION
Amy, RN (primary nurse), post anesthesia care unit.
Your name, position (RN), unit you are
working on

SITUATION Doris Bowman, 39 years-old, patient underwent a total

Patient’s name, age, specific reason for visit abdominal hysterectomy with bilateral salpingo-oopherectomy
with general anesthesia. Patient tolerated the procedure with
no complications. Patient is now in the PACU recovering.

BACKGROUND Patient’s primary diagnosis is postoperative abdominal

Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT
Current pertinent assessment data using
head to toe approach, pertinent diagnostics, She has an abdominal incision covered with 4x4 gauze dressing
vital signs
hysterectomy with bilateral salphingo-oopherectomy. Date of
admission is 6/7/20. Patient’s current orders include:
Diet: sips of water advance to clear liquids as tolerated
Activity: out of bed tonight
ECG monitoring
Post-operative vital signs
Oxygen to maintain SpO2 greater than 92%
IV: Potassium chloride in 5% dextrose and normal saline at 125
mL/hr
Indwelling Foley catheter
Medications: Morphine 2mg IV push, may repeat up to 10mg
every 4 hours. Administer morphine as ordered If pain score
greater than or equal to 4 (0-10 scale). Ondansetron 4mg IV
push every 4 hours PRN nausea. Naloxone 0.2 mg IV push every
2-3 minutes PRN respiratory rate less than 6 or change is level of
consciousness.
Transfer to surgical floor.
Upon Assessment:
Patient tolerated the procedure without complications.
IV of potassium chloride in 5% dextrose and normal saline
infusing at 125 mL/hr. Estimated blood loss was 400mL
She was extubated in the operating room and is breathing
spontaneously at 21 bpm.
She had a Foley catheter places with 200mL urine output
Compression stockings have been applied.
ECG: sinus tachycarida
Heart rate: 111
Pulse: present
Blood Pressure: 152/91 mmHg

This study source was downloaded by 100000809397024 from CourseHero.com on 09-13-2022 21:43:03 GMT -05:00

https://www.coursehero.com/file/65517773/SBAR-Doris-Bowmandocx/
 Respiration: 21
Conscious state: appropriate
SpO2: 95%
Temp: 99 F (37C)
Pain: 6/10

Patient was administered 2mg Morphine for pain score of 6 on

scale of 0-10. Respiratory rate decreased and patient was
administered Naloxone 0.2mg

RECOMMENDATION The patient seems to be doing fairly well post-operation besides

Any orders or recommendations you may some pain which is normal. Patient’s pain level should be
have for this patient continued to be monitored and managed with proper
medications. Patient’s vital signs should continue to be
monitored. Patient should work towards ambulating as soon as
possible. Patient’s diet should be increased when she is able to
tolerate it.

This study source was downloaded by 100000809397024 from CourseHero.com on 09-13-2022 21:43:03 GMT -05:00

https://www.coursehero.com/file/65517773/SBAR-Doris-Bowmandocx/
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