SASHADONE

SBAR CLINICAL WORKSHEET – PEDIATRIC – ALEXANDER KOVALIK (SASHA) Student Name: Rebecca Downs Dates of Care: May 27 2020 S Medical Diagnosis/and or surgical procedure: (include definition and why surgery performed) Appendicitis Appendectomy Significant past history: Allergies: NKDA Code status: Age: 10 *If altered, indicate why Lab values: (include norms) Hgb Hct RBC WBC Differential INR Platelets K+ Na+ Cl- CO2 FBS BUN Creatinine Urinalysis Cultures/Others Diagnostic Tests (Recent) Client Medication Information (Drug name, Dose ordered, Normal Adult dose, Time ordered for, and Purpose and Nursing Implications) *Attach on a separate sheet* Priority Nursing Diagnosis . 3 Interventions for each diagnosis 1. Acute pain related to presence of surgical incision evidenced by reports of pain. Administer pain medications as needed Assess pain level frequently Provide accurate information to patient 2. At risk for infection related to invasive procedure. Infection control measures Examine for signs of infection and irritation Review lab work (WBC) 3. At risk for complications related to recent abdominal surgery. Assess surgery site frequently Educate patient on signs and symptoms to report Infection control measures In Collaboration with client identifies health teaching needs : -Infection control measures when it comes to dressing care -When needing to cough it is important to use a pillow across the abdomen -Teaching that the surgery pain will not last forever.

B Background Transfer status □Mech Lift □ 1-person □ 2-person □ Independent Falls/Risk □Yes ✔ No Assistive devices_____________ Allergies □Yes ✔ No Infection control □ MRSA □ VRE □ C-Diff □ Other Assessment GLUMS (ordered/how often) Diet and % of meal taken NPO A Vital signs T______ P_____ R 26 BP________ SPO 2 94% RA Time Result Time T______ P_____ R 24 BP________ SPO 2 97% RA Time Result Time T______ P_____ R_____ BP________ SPO 2 _____ Time Result Time T______ P_____ R_____ BP________ SPO 2 _____ Time Result Time Neurological Assessment Ox3 Cardiac Assessment WDL Neurovascular Assessment (6P’s) WDL Respiratory Assessment Diminished air entry bilaterally lower lobes Gastrointestinal Assessment Abd round and symmetrical Hypafix dressing RLQ intact, dark red spot noted approx. 2cm Steri strips to umbilical area, dry and intact Hypoactive BS all 4 quads, tympanic sounds throughout Abd soft to touch, no tenderness on light palpation Genitourinary Assessment WDL Catheter Musculoskeletal Assessment Sensation intact Pedal pulses intact Skin/Wound Assessment Incision RLQ dry and intact Steri strips and 4x4 Drains Pain Assessment -Sharp pain when deep breathing and coughing -Pain worsens when moving, is better when still -5/10 Psychosocial Assessment -Concern surgery pain will last for a long period of time IV solution, rate and site Ampicillin 363mg 33ggts/min NS Intake Output

Patient Medications Ampicillin 336mg IV x3 Acetaminophen 325mg PO q4h Morphine 1mg IV q4h PRN Morphine 5mg PO once tolerated Dimenhydrinate 25mg PO q6h