Teaching Plan SBAR 11_14
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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
7
Uploaded by caithomasadn
1
Teaching Plan
/
SBAR
Caitlin Thomas
Chamberlain University
NR: 447 Community Health
Heaven Simms MBA DNP RN FCM PHNA-BC NE-BC
November 14, 2023
2
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 lower inner quadrant of right female breast. Patient
has no known allergies. There are no advanced directive documents on file, no isolation precautions ordered. Patient
has completed the pre-anesthesia questionnaire, and answer were reviewed and confirmed correct with the patient. Patient has standard HIPPA code ordered. Physician is Dr. Sumaira. There are no activity modifications for this patient at the moment as 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. Patient had consult with plastic surgery at 0840 on 10/31/2023 prior to 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
11/08/2023 Tramadol (ULTRAM) 50 MG tab PO Q6H PRN
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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 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 lower inner quadrant of 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, or suspicious calcifications, enhanced mass or non-mass enhancement are identified. 03/31/2023: RIGHT BREAST/NODAL BASINS ULTRASOUND
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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, realtime 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 ; Patient was originally scheduled for surgery on 11/04 for 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 risk. The surgery was rescheduled to and completed on 11/08/2023.
related medication history: 04/26/2023
Treatment Plan
BR OP: Pembrolizumab, PACLitaxel and CARBOplatin weekly
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,
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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:
[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:
[plan is still active]
Socioeconomic HX: Occupation:
currently retired. Patient was a medical assistant in the medical system in Mexico, 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:
Spanishor Latino
Ethnicity/race:
White or Caucasian/ Hispanic 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
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son to help care for her grandchildren so they wouldn’t have to attend day care. The patient was diagnosed with infiltrating ductal carcinoma of lower inner quadrant of right female breast on 02/24/23 after palpating a mass during
a self-breast exam. Port was placed in April 4th 2023 for chemotherapy, 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 note 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 management of present illness: perceived concerns would be not waiting the appropriate time to rest and recover postoperatively. Gender roles are predominant in Latino and Hispanic culture. The women typically take care of the housework and childcare. Postoperative instructions require no bending, stooping or heavy lifting for at least six weeks. Her 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. Patient is continuing chemotherapy treatment, shows thorough understanding of procedures and port cath care. No perceived concerns with 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 can 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: patient appears pale and thin, ambulates well, speech is clear and cohesive, gait is steady
Head: atraumatic, normocephalic, alopecia present
RESP: pt does not report any dyspnea, sob, or difficulty breathing upon assertion. Chest rises evenly, contour and symmetry are the same, there is no apparent use of accessory muscles.
Skin: pale no bruises, lesion, 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:
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Economic Stability: Patient is of middle to upper middle class standing. States that she has a 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: Patient is retired. Her and her husband collected a substantial retirement fund. The exact amount is not specified.
Expenses: 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 state’s her son is an engineer and her daughter in law is a teacher, they live in a nice home in a nice neighborhood.
Debt: Patient declined having any debt
Medical Bills:
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 accompany her to appointments, and often has her friend from church attend appointments with her if her children cannot take her. She is supported spiritually and emotionally from her immediate family and church congregation members.