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SBAR

1) Nurse Nabiela reported to the doctor about Mr. Alan, a 55-year old patient diagnosed with diabetes mellitus who has been feeling weak, dizzy, and having trouble sleeping. 2) Mr. Alan's vital signs and lab results indicated high blood pressure, rapid respiration, high pulse, and blood glucose of 420 g/dl. He also had wounds on his toes and bad skin turgor. 3) The nurse assessed the problem as ineffectiveness in controlling blood glucose levels and impaired skin integrity. 4) The doctor recommended monitoring blood glucose, giving an intravenous fluid mixture of NaCl and RL at a 1:1 ratio, and having the patient do walking exercises.

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Nabiela Aswaty 2011125083
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464 views2 pages

SBAR

1) Nurse Nabiela reported to the doctor about Mr. Alan, a 55-year old patient diagnosed with diabetes mellitus who has been feeling weak, dizzy, and having trouble sleeping. 2) Mr. Alan's vital signs and lab results indicated high blood pressure, rapid respiration, high pulse, and blood glucose of 420 g/dl. He also had wounds on his toes and bad skin turgor. 3) The nurse assessed the problem as ineffectiveness in controlling blood glucose levels and impaired skin integrity. 4) The doctor recommended monitoring blood glucose, giving an intravenous fluid mixture of NaCl and RL at a 1:1 ratio, and having the patient do walking exercises.

Uploaded by

Nabiela Aswaty 2011125083
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© © All Rights Reserved
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Nabiela Aswaty

2011125083
A 2020 2
Group 4

USL REPORTING OF PATIENTS HEALTH PROBLEM


Lecturer: Ns. Nurhannifah Rizky Tampubolon, M. Kep

Scenario
Mr. Alan (55 years old) has been hospitalized in AA hospital for 3 days in Bougenville’s
ward. Mr. alan has diagnosed with diabetes mellitus. Patient complain of still feeling weak,
dizzy, and having trouble sleeping. Nurse N tried to report the patient's complaining
condition to the doctor and asked for recommendations on what measures should be given to
Mr. Alan.

SBAR
Situation (S) :
- Mr. Alan feels weak, dizzy, and has trouble of sleeping
- Vital signs : Blood pressure 140/98 mmHg, RR 26 per minute, Pulse 93 per minute,
composmentist, bad skin turgor.
Background (B) :
- Diagnose with diabetes mellitus
- Monitor blood glucose periodically, assess skin integrity
- Insulin injection, intravenous NaCl 0,9%
- Laboratory results : leukosit 12,4 (10^3/ul), blood glucose 420 g/dl
- Wounds on the toes accompanied by swelling
Assesment (A) :
- Problem of ineffectiveness of blood glucose levels and impaired skin integrity
Recommendation (R) :
- Monitor blood glucose, physical exercise such as walking, give a ratio of intravenous
fluids NaCl and RL 1:1
Dialogue
Nurse : Assalamualaikum, good morning doctor.
Doctor : Waalaikumsalam, good morning.
Situation (S)
Nurse : I’m Nabiela, nurse on ward Bougenville. The reason why i am calling is because
Mr. Alan in room 127 still feels weak, dizzy, and having trouble of sleeping. I am
concerned that his blood pressure is 140/98 (one fourty ninety eight) mmHg,
respiration rate is 26 per minute, pulse 93 per minute. Mr. Alan awareness is
composmentist and bad skin turgor. Also, he has wounds on the toes accompanied
by swelling.
Doctor : Alright, could you tell me about the patient?
Background (B)
Nurse : Mr. Alan is a 55 years old who has admitted on 25 November 2022 (twentyfive
november two thousan and twenty two) with diabetes mellitus. The measures that
has been taken are periodic blood sugar monitoring, asses his skin integrity, and got
NaCl 0,9% intravenous fluid with 20 drops/minute. Also, he got insulin injection to
control his blood glucose. His recently laboratorium results showed that his leukosit
is 12,4 (10^3/ul), blood glucose 420 (fourhundred twenty) g/dl and it’s still high.
Doctor : Okay, what do you think the problem is?
Assesment (A)
Nurse : I think the problem is ineffectiveness of blood glucose levels and impaired skin
integrity. Mr. Alan is not in the stable condition.
Doctor : So, Mr. Alan is not in the stable condition because of ineffectiveness of blood
glucose levels.
Recommendation (R)
Nurse : Yes, Doc. Is there anything i need to do? Should i monitor the blood glucose?
Doctor : Alright, i will come to see the patient in the next 10 mins and you should give him
a ratio of NaCl intravenous fluid and RL with 1:1 (one to one), and also physical
exercises such as walking exercise to lower the blood glucose, keep monitor his
blood glucose.
Nurse : Okay doc, i'll begin with give a ratio of NaCl and RL intravenous fluid in a ratio of
1:1. After that I will help Mr. Alan to do physical exercise such as walking and
monitor his blood glucose. Thankyou, doctor.

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