SBAR: Situation-Background-Assessment-Recommendation Student Name Sussan Lopez Date 06/05/2020

Before filling out the template, first save the file on your computer. Then open and use that version of the tool. Otherwise, your changes will not be saved.

Template: SBAR – Postpartum care

This is Sussan Lopez SLPN from the Mother/Baby/Postpartum. I am calling about Mrs.
S Situation: What Is the situation you are calling
about (End of Shift Report)? T.N. The patient delivered a healthy male infant 2 hours ago, and is now in the

a
• Identify self, unit, patient, room number. postpartum unit.

vi
• Briefly state the problem, what Is it, when it
happened or started, and how severe.
Background: Pertinent background information Patient is gravida 6. Before this birth, she was para 4014.
B

d
related to the situation could include the following:
Patient had a vaginal delivery with an epidural block for labor pain.

e
• The admitting diagnosis and date of admission
• List of current medications, allergies, IV fluids, and

ar
labs Pt had a midline episiotomy.
• Most recent vital signs Recent vitals include:

sh
• Lab results: provide the date and time test Temperature : 99.9 ° F (37.7 ° C) oral
was done and results of previous tests for Pulse rate : 120 beats/min
comparison
Blood pressure : 100/50 mm Hg

as
• Other clinical information
Respiratory rate : 16 breaths/min
• Code status

w
Assessment: Whal is the nurse's assessment of the Upon assessment of patient, findings included:
A situation? - Boggy fundus: massaged uterus until fundus was firm.

m e
- Pt c/o pain and discomfort in perineum; inspected site and applied topical spray
and ice pack to area. Encouraged sitz bath, with cool water for first 24 hrs, then
co rc warm water after to promote circulation and healing.
- Patient has tachycardia, and slighty elevated temp.
o. ou
- After 1 hr of admission, checked perineal pad, found small amount of drainage
on pad, proceeded to check pad undearneath buttocks.
er res
- Assessed for bleeding, color, amount and odor or lochia. Assess routinely
fundus.
I recommended the following patient care/education:
R Recommendation: What is the nurse's
- Apply ice to perineum, use topical anesthetic spray, give pain medication as
se dy

recommendation or what does he/she want?

Examples:
necessary. Encourage sitz baths using cool water for 24 hours to lower edema.
• Notification that patient has been admitted
Warm water 24 hours after to promote circulation and healing.
- Monitor vitals on patient every 2 hours, until tachycardia resolves.
ur tu

• Patient needs to be seen now - Monitor the fundus, if boggy, massage until firm.
- Promote ambulation to decrease risk of blood clots and constipation.
s
H

• Order change - Use of stool sofetners.

is

- Increase fluid intake for re-hydration.

- Lactation consult for breastfeeding patient education.
Th

- Newborn care.
- -05:00
This study source was downloaded by 100000807808823 from CourseHero.com on 09-23-2021 05:58:47 GMT Danger signs excessive bleeding and signs and symptoms of infection chills
fever redness the breast or incisions. Foul smelling discharge.
 - Postpartum care, teach Kegel exercises to strengthen peri-muscle and other
exercises to strengthen abdominal muscles. rest naps and limit visitors.
- Use of Contraception after initial follow up post partum visit.

Institute for Healthcare Improvement · lhl,org I This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials In the spirit of patient safety, and please
retain this footer In the spirit of appropriate recognition

a
vi
e d
ar
sh
as
w
m e
co rc
o. ou
er res
se dy
ur tus
H
is
Th

This study source was downloaded by 100000807808823 from CourseHero.com on 09-23-2021 05:58:47 GMT -05:00
Powered by TCPDF (www.tcpdf.org)