Teaching plan _ SBAR week 6
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School
Lone Star College System, Woodlands *
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Course
MISC
Subject
Medicine
Date
Jan 9, 2024
Type
docx
Pages
14
Uploaded by caithomasadn
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Teaching Plan
/
SBAR
Caitlin Thomas
Chamberlain University
NR: 447 Community Health
Heaven Simms MBA DNP RN FCM PHNA-BC NE-BC
November 14, 2023
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SBAR
Situation:
GL is a 61-year-old female patient presenting to the perioperative evaluation and management department on 10/31/2023 at 10:00 for a preoperative evaluation for a double mastectomy scheduled on 11/04/2023. The primary medical diagnosis is infiltrating ductal carcinoma of the lower inner quadrant of the right female breast.
The patient has no known allergies. There are no advanced directive documents on file, and no isolation precautions have been ordered. The patient has completed the pre-anesthesia questionnaire, and the answers were reviewed and confirmed correct with the patient. The patient has a standard HIPPA code ordered. The physician is Dr. Sumaira. There are no activity modifications for this patient at the moment as the patient ambulates well and is a low fall risk. Vital signs are as follows: B/P: 129/30 HR: 86 RR: 16 T: 98.7 F oral O2 Sat: 99% room air. The patient had a consult with plastic surgery at 0840 on 10/31/2023 before an appointment with POEM. The patient speaks Spanish and requires an interpreter or Spanish-speaking provider.
Background: Medical HX:
Disorder of the thyroid gland 01/10/2010.
Rheumatoid arthritis 01/10/2010
Menopause: 06/15/2021
Diverticulitis 08/01/2021
Cyst of breast 02/06/2023
Malignant tumor of right breast 03/13/2023
Significant Family Medical HX:
Lymphoma- maternal grandmother- deceased Uterine Cancer- Mother- Deceased at age 72
Other- Father- Deceased at age 72
Tongue cancer- maternal cousin- deceased at age 28
Current medications:
11/11/2023 Ibuprofen (Advil, Motrin) 800 mg tab PO Q8H
11/09/2023 Doxycycline (VIBRAMYCIN) 100 mg tab PO BID
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11/08/2023 Tramadol (ULTRAM) 50 MG tab PO Q6H PRN
11/08/2023 Acetaminophen (TYLENOL) 325 Mg tab PO Q6H PRN
11/07/2023 Lidocaine-prilocaine (EMLA) 2.25% cream 1 application
08/07/2023 Levothyroxine (SYNTHROID) 112 mcg tab PO DAILY BEFORE BREAKFAST
07/30/2023 Atorvastatin (LIPITOR) 10 mg tab PO at bedtime 07/30/2023 Ondansetron (ZOFRAN) 8 mg tab PO Daily for 3 days after chemotherapy treatment then 1 tab Q8H PRN
07/30/2023 Pantoprazol (PROTONIX) 40 mg EC TAB PO DAILY Unknown date: Temazepam (RESTORIL) 30 mg CAPSULE PO DAILY AT BEDTIME
Unknown date: Cetirizine (ZYRTEC) 10 Mg tab PO DAILY PRN
Allergies
: NKDA
History of present illness/primary medical diagnosis:
02/17/2022 OSI screening mammogram: focal asymmetry in the left breast at 12:00
02/24/2023 OSI diagnostic mammogram: mass in right breast lower inner aspect anterior depth
02/24/2023 OSI US: 1.5 cm mass in the right breast at 4:00 middle depth 4 cm FN
03/06/2023 OSI diagnostic mammogram: mass in the right breast at 4:00 middle depth
03/06/2023 OSI Ultrasound-guided biopsy: right breast, 4:00. Invasive ductal carcinoma, intermediate grade, ER 0%, PR 0%, HER-2 score 0 Ki-67 90%
03/31/2023: INITIAL DIAGNOSIS: infiltrating ductal carcinoma of a lower inner quadrant of the right female breast.
03/31/2023: BILATERAL DIAGNOSTIC MAMMOGRAM 3D WITH CONTRAST:
RIGHT BREAST:
Obscure mass with central necrosis measuring 2.6 cm at 4-5:00 position, 6mm FN. Outside pathology revealing IDC
Mild skin thickening along the inferior aspect of the right breast representing post-biopsy changes
LEFT BREAST:
In the left breast, no dominant mass, distortion, suspicious calcifications, enhanced mass, or non-
mass enhancement are identified.
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03/31/2023: RIGHT BREAST/NODAL BASINS ULTRASOUND
HYPOECHOIC MASS MEASURES 1.8 cm AT 4-5:00 POSITION, 6 cm FN. No suspicious lymphadenopathy of the right regional nodal basin. 04/03/2023: DX- cancer staged -
Clinical stage: Stage IIB (cT2, cN0, G2, ER-, PR-, HER2-)
Surgical Hx
: 1982, 1985, 1992: Cesarean section, Low transverse
1992: Tubal litigation
2007: Knee arthroscopy w/ debridement
01/10/2010: COLONOSCOPY
04/26/2023: PR US VASC ACCESS SITS VSL PATENCY NDL ENTRY, LEFT LATERAL (US guidance with eval of potential access sites, real-time visualization of vasc needle entry.)
04/26/2023: PF FLUORO CENTRAL VENOUS ACCESS DEV PLACEMENT, LEFT LATERAL (fluoro guidance
for central venous access device placement, replacement, or removal.)
04/26/2023: PR INSJ TUNNELED CTR VAD W/ SUBQ PORT AGE 5 YR/> (insertion of tunneled centrally inserted central venous catheter with subcutaneous port.)
11/08/2023: PR BX/EXC LYMPH NODE OPEN DEEP AXILLARY NODE, RIGHT (sentinel node biopsy-axilla)
11/08/2023: PR INTRAOP SENTINEL LYMPH NODE ID W/ DYE INJECTION
11/08/2023: PR MASTECTOMY SIMPLE COMPLETE, RIGHT
11/08/2023: PR MASTOPEXY, LEFT
11/08/2023: PR TISSUE EXPANDER PLACEMENT BREAST RECONSTRUCTION, RIGHT
COMMENTS; The Patient was originally scheduled for surgery on 11/04 for a double mastectomy, the patient changed their mind about removing the left breast as a prophylactic measure, after considering all the options, education, counseling, and weighing the benefits vs the risks. The surgery was rescheduled and completed on 11/08/2023.
related medication history: 04/26/2023
Treatment Plan
BR OP: Pembrolizumab, PACLitaxel, and CARBOplatin weekly
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Chemotherapy Summary PAClitaxel (TAXOL) 135 mg in sodium chloride 0.9% (NON-PVC) 250 mL IVPB, intravenous, 4 of 4 cycles.
Pembrolizumab (KEYTRUDA) 200 mg in 0.9% NaCl (NS) 50 ml IVPB, intravenous,
4 of 4 cycles.
CARBOplatin (PARAPLATIN) 145 mg in D5W, 250 mL IVPB, intravenous 4 of 4 cycles
Treatment Dates
04/26/2023 to 07/28/2023
Line of Treatment
Solid: Neoadjuvant Therapy
Treatment Goal:
Discontinue Reason:
[the plan is still active]
08/11/2023
Treatment Plan
BR OP: Pembrolizumab, DOXOrubicin, and cyclophosphamide (AC)
Chemotherapy Summary cyclophosphamide (CYTOXAN) 1056 mg in 0.9% NaCl (NS) 250 mL IVPB, intravenous 4 of 4 cycles
DOZOrubicin (ANDRIAMYCIN) 2 mg/mL IVPB 106 mg, intravenous, 4 of 4 cycles
Pembrolizumab (KEYTRUDA) 200 mg in 0.9% NaCl (NS) 50 ml IVPB, intravenous,
4 of 13 cycles.
Treatment Dates
08/11/2023 to 04/19/2024 (Planned)
Line of Treatment
Solid: Neoadjuvant Therapy
Treatment Goal:
Discontinue Reason:
[the plan is still active]
Socioeconomic HX: Occupation:
currently retired. The patient was a medical assistant in the medical system in Mexico and became a homemaker after relocating to the United States. Marital Status:
Widowed
Number of children:
3
Years of education/ Highest Education Level:
15 years, High School Graduate
Preferred Language:
Spanish Ethnicity/race:
White or Caucasian/ Hispanic
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The patient is from Mazatlán, Sinaloa, Mexico, and moved to the United States in 2000. She lives in Spring, Texas with her 31-year-old son, his wife, and her 2 grandchildren. She was a medical assistant in Mexico, and a homemaker after moving to the United States. When her husband passed away from heart failure in 2019, she moved in with her son to help care for her grandchildren so they wouldn’t have to attend daycare. The patient was diagnosed with infiltrating ductal carcinoma of a lower inner quadrant of the right female breast on 02/24/23 after palpating a mass during a self-breast exam. Port was placed on April 4th, 2023 for chemotherapy and, a double mastectomy scheduled for 11/9/23.
perceived/stated issues:
Concerns would be post-surgical care and recovery considering she is a primary caregiver of two small children ages
2 and 6. She will not be able to lift anything heavy, including the two-year-old grandchild. Her son attended the preop appointment with her and took thorough notes of instructions and education for the night before the procedure. She seems to have a high health literacy and understanding of instructions. Her stated concern was recovery time as she is the primary caretaker of the home and caretaker of her grandchildren during the work week hours. concerns with the management of the present illness: perceived concerns would be not waiting for the appropriate time to rest and recover postoperatively. Gender roles are predominant in Latino and Hispanic cultures. The women typically take care of the housework and childcare. Postoperative instructions require no bending, stooping, or heavy lifting for at least six weeks. She and her son showed understanding and willingness to follow postoperative procedures and care, but often people fall into their usual routine leading to complications in healing time. The patient is continuing chemotherapy treatment and shows a thorough understanding of procedures and port cath care. There are no perceived concerns with the management of
chemotherapy treatments
treatments (medicinal and non-medicinal) that have worked well: Chemotherapy was successful in shrinking the tumor in the right breast to where the patient stated she could no longer feel the mass in the right breast upon palpation, mass was measured at 1.3 cm on 7/03/2023 via ultrasound. Assessment: Gen: The patient appears pale and thin, ambulates well, speech is clear and cohesive, and gait is steady
Head: atraumatic, normocephalic, alopecia present
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RESP: the patient does not report any dyspnea, shortness of breath, or difficulty breathing upon assertion. Chest rises evenly, contour and symmetry are the same, and there is no apparent use of accessory muscles.
Skin: pale no bruises, lesions, or discolorations. Color is even and appropriate for ethnicity
Neuro: A&O x 4, dress is appropriate for the weather, mood and affect is calm and content
Social determinants of health:
Economic Stability: The patient is of middle to upper-middle-class standing. States that she has significant retirement savings, and is retired. Her son is an engineer with a well-established career history and her daughter-in-law is a tenured high school teacher. Her other son is a realtor and her daughter is a CPA.
Employment: Not currently employed; previously worked as a medical assistant in Mazatlan, Sinaloa, Mexico.
Income: The patient is retired. She and her husband collected a substantial retirement fund. The exact amount is not specified.
Expenses: The patient did not wish to disclose any expenses that she has, she stated that she lives with her son and only has the expense of her car note (Lexus) and lives in her son’s home with his wife and two children, in The Woodlands (Spring), Texas. She states that her son is an engineer and her daughter-in-law is a teacher, they live in a nice home in a nice neighborhood.
Debt: The patient declined to have any debt
Medical Bills:
The patient has private health care coverage and declines any outstanding medical expenses.
Support: The patient expresses she is a devout Catholic, expresses that one of her three children accompanies her to appointments, and often has her friend from the church attend appointments with her if her children cannot take her. She is supported spiritually and emotionally by her immediate family and church congregation members. Community Considerations:
Housing: The patient currently resides in a single-family home owned by her son and daughter-in-
law in Spring, Texas in the 77379 zip code zoned to Klein Independent School District. She shares
the home with her son, his wife, and two children.
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Transportation:
The patient owns a vehicle and can drive. The patient states that when she has to
attend appointments alone, she can drive to and from the appointments, however, she does not like
to drive and often has her son or daughter-in-law drive her to her appointments. Metro bus routes do not run to, or throughout, the city of Spring, area code of 77379, and the surrounding areas. o
Community Transportation Considerations: The closest public transportation options to commute to M.D. Anderson Cancer centers are metro park and ride locations including
Spring Park & Ride located at 17444 Carlsway Rd, Houston, TX 77073 which is 9.2 miles from the center of the 77379 area code zone, Kuykendahl Park & Ride, located at 12920 Kuykendahl Rd, Houston, TX 77090 which is 9.2 miles from the center of 77379 area code zone, and Research Forest Park & Ride located at 3900 Marsico Pl, Spring, TX
77380 which is 15.2 miles from the center of the 77379 area code zone. Other transportation options include ride share such as Uber or Lyft, taxi cabs, and metro lift.
Safety:
Based on data from Crime Grade (n.d.), Spring, Texas (77379) has received a C+ grade for its crime rate. This indicates that the level of crime is roughly on par with the average US zip code. In terms of safety, 77379 ranks in the 47th percentile, meaning that 53% of zip codes are considered safer while 47% are considered more dangerous. The standard yearly crime rate in 77379 is 31.10 per 1,000 residents. Residents of 77379 tend to view the southeast area of the zip code as the safest. Depending on the neighborhood, your chances of falling victim to crime in 77379 can range from 1 in 10 in the northwest to 1 in 71 in the southeast. Spring, Texas has a 1 in 393 chance of experiencing violent crime and a 1 in 62 chance of experiencing property crime. The violent crime rate in Spring is 35, which is 12.3 points higher than the national rate of 22.7.
Parks: There are three large parks in proximity to 77379 including Meyer Park, Collins Park, and Klein Park. These three parks feature paved walking trails, unpaved hiking trails, exercise stations,
and creek-side mountain bike trails. Meyer Park and Collins Park also feature soccer fields and basketball courts.
Playgrounds: There are playgrounds featured at Meyer Park, Collins Park, and Klein Park, which are the three large parks in proximity to 77379. There are also multiple playgrounds featured
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throughout the communities including splash pads, public pools, neighborhood playgrounds, and playgrounds provided and maintained by the Department of Parks and Recreation.
Walkability: Not only is the lack of public transportation a concern for the community of Spring, Texas, but after completing a windshield assessment, the walkability of the community is low, and
bike-ability is even lower posing barriers to transportation to and from health care appointments and safety concerns navigating automobile traffic by foot or bicycle. The sidewalks are not complete throughout the community, nor would they be considered easily manageable for those with assistive mobility devices such as walkers and wheelchairs because the concrete is broken or non-existent in some areas. According to Walk Score (n.d). Spring, TX. 77379 is “car-dependent” with a score of 44 out of 100 points most errands are car-dependent, and the bike-ability score is 41 out of 100 points, with minimal infrastructure to facilitate safe cycling for running errands.
Zipcode: geography Zip code 77379 is located in the city of Spring, Texas, which is a suburb located near the Houston Texas metropolitan area.
Education:
Literacy:
The patient is competent in cultural and conceptual knowledge, indicating a high level of literacy. Additionally, as a former medical assistant, it can be concluded that the patient has a strong health literacy related to her education and professional background.
Language:
The patient is Spanish-speaking as her first language, and is proficient in multiple languages speaking moderate English as a second language, reflecting a multicultural and multilingual ability.
Early Childhood Education:
The patient attended preschool and primary school in Mexico, starting at the age of 4.
Vocational Training:
The patient's vocational training background is in the medical field as a medical assistant in Mazatlán, Mexico. As a medical assistant, she stated most of her career was spent at an outpatient orthopedics practice specializing in sports injuries.
Higher education: The patient attended the National Autonomous University of Mexico, in Mexico City to obtain a medical assistant certificate.
Food:
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Hunger:
The patient states she does not have any food insecurities. In her community measures to
address food insecurity for the population include Texas Supplemental Nutrition Assistance Program. Women Infants and Children (WIC), and Interfaith Ministries food bank.
Access to healthy options: The patient states she shops at the local H-E-B grocery store for fresh produce and occasionally visits the local farmer’s market for seasonal produce.
Community and social context
Social integration: The patient attends church services on Sundays, and bible study group on Wednesday evenings. She explains that she has friends in her congregation who attend appointments with her on days her family cannot take her. She explains that the congregation often participates in charity events which she used to participate in before starting chemotherapy treatment. The patient explains that since starting chemotherapy treatment, she has not participated
much in these events to avoid large crowds and gatherings due to her compromised immune system.
Support systems: The patient receives support from her son and his wife, who are described as actively involved in her care and treatments. Additionally, the patient notes spiritual support from her church congregation and religion. The patient states she does have children living in Mexico that she has not gotten to visit since starting chemotherapy treatment due to taking precautions since becoming immunocompromised, however, she explains she keeps frequent communication with the family that resides out of the country. Concerns regarding postoperative care support would be that she is a primary caregiver of her two young grandchildren. Also, she states that her son is going to be the primary support in her postoperative care. Cultural considerations would be that in Latino and Hispanic cultures women are the primary caregivers of the home, her son might be willing but lack the knowledge or ability to fully provide care for her, as well as be uncomfortable with caring for his mother’s breasts after her mastectomy. Another concern would be her willingness to accept the care and not try to push herself to resume her role as a caregiver too soon after surgery.
Community engagement: Given the limited ability to participate in her usual community and social engagement due to her compromised immune system as a result of chemotherapy, she might
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feel a sense of isolation and distance from her usual social support. Psychosocial assessment and integrity are important to consider at this time. However, the patient states that the support from her congregation provides a social and spiritual connection.
Discrimination:
The patient does not report any instances of feeling subjected to discrimination. However, it is important to consider that being an immigrant from Mexico who speaks limited English, she does present factors that could subject her to discrimination from different cultures in the community. Additionally, I believe it is important to note that the population in Spring, Texas is 41% Hispanic or Latino and there is an opportunity for her to integrate into a social setting with those from a similar culture and background.
Stress: The patient is under increased stress due to factors such as loss of independence to a certain degree, requiring her son to care for her in the postoperative phase, commuting to the Texas Medical Center from Spring, Texas, and potential barriers in accessing necessary healthcare. The individual is facing a multitude of stressors that have the potential to affect different areas of their life. However, they have found solace in their faith and religious practices, which have provided them with effective ways to alleviate stress. Despite the challenges they are facing, the person remains optimistic, maintaining a positive outlook and a determined attitude to overcome this temporary setback.
Health care system
Health coverage: The patient has private insurance through Blue Cross Blue Shield of Texas as well as a health care savings account which helps cover medical expenses.
Provider availability: The patient explains that her primary care provider is located in Spring, Texas and her oncologist is located at M.D. Anderson Cancer Center at Texas Medical Center. She also explains that her plastic surgeon has been involved in collaborative care regarding her breast reconstructive surgery following her mastectomy.
Provider and linguistic and cultural competence: She is originally from Mexico. She speaks Spanish as her first language and a moderate amount of English as her second language and speaks English well enough to manage short conversations on her own, but is not fluent in the
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language and requires a translator or Spanish-speaking health care provider for her health care provider visits.
Quality of care: The patient has expressed a preference for a holistic approach to her care and has
conveyed satisfaction with the level of care she has received from her healthcare providers. She believes that incorporating supportive individuals from her personal life, community, and religious
circle could greatly enhance her overall care experience.
cultural assessment:
The patient originates from Mazatlán, a city located in the state of Sinaloa, Mexico. During the consultation, the patient conveyed that she is an active member of her local congregation and holds a deep devotion to her Catholic faith. She further elaborated that her community and religion have been a source of unwavering spiritual support throughout her life.
Determine health literacy needs and potential or actual barriers to learning: The patient possesses strong cultural and conceptual knowledge, as well as excellent listening, speaking, writing, and reading skills. Her health literacy is above adequate for understanding teaching and perioperative care instructions.
Recommendation:
Follow up with oncologist, plastic surgeon, and primary care physician 1-2 weeks after surgery. Call the POEM department regarding any questions or concerns related to the impending surgery.
Teaching Plan:
What will you be teaching this patient and why?
Discontinue any medications that are contraindicated with surgery 24-48 hours before the scheduled appointment. (will detail which ones) Do not eat or drink anything after midnight the night before the surgery.
Do not drink water or coffee on the morning of the surgery.
You must have someone with you at the facility during the surgery, and someone to drive you home. You cannot leave the facility alone.
There will be a Jackson Pratt drain in place following the surgery, notify the physician if you experience any heat, redness, swelling, sanguineous or purulent drainage, or foul odor from the incision site. Notify the physician if you develop a fever or nausea as this may be a sign of infection.
Do not lift anything, bend, or stoop at the waist until the physician has instructed you to resume normal activities.
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Take medications as scheduled and directed to avoid any complications and control postoperative pain.
Inspect the incision site daily to assess for signs and symptoms of infection or other serious complications. Ambulate as soon as possible following surgery to prevent deep vein thrombosis.
Drink plenty of fluids and report any signs of decreased urination,
Use an incentive spirometer once every hour for 24 hours after surgery to prevent complications such as atelectasis or pneumonia.
Shower daily to keep the incision clean and dry to prevent infection.
Practice coughing and deep breathing exercises.
Consume an adequate diet high in protein and moderate carbohydrates to promote effective wound healing
Consume an adequate amount of fiber to prevent constipation
Opioid analgesics can cause drowsiness, lightheadedness, dizziness, and constipation. Use caution when ambulating to prevent injury.
Rise slowly when ambulating, sit on the edge of the bed, and place feet on the floor for a short time before standing up to prevent orthostatic hypotension and injury.
Remove all fall hazards such as clutter on the floors of the home, cords, and throw rugs to prevent injury.
Return to a normal diet as tolerated following surgery.
Resume medication regimen as directed by your physician following surgery.
Call your primary provider with any questions or concerns.
What is your expected outcome following the teaching session?
The patient is informed and shows an understanding of preoperative and postoperative instructions and teachings. Her son shows an understanding of teaching as well and the patient was sent home with written instructions regarding preoperative and postoperative care. The expected outcome is that the patient will successfully follow pre and postoperative teachings and be free of complications following the mastectomy.
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References:
Crime Grade. (n.d.). The Safest and Most Dangerous Places in 77379, TX: Crime Maps and Statistics
. Crimegrade.org.
Walk Score. (n.d.). Spring TX - Walk score
. WalkScore.com. https://www.walkscore.com/score/spring-tx