Question

T.N. delivered a healthy male infant 2 hours ago. She had a midline episiotomy. This is her sixth pregnancy.

Before this delivery, she was para 4014. She had an epidural block for her labor and delivery. She is now

admitted to the postpartum unit. Vitals are: Pulse rate 120 beats/min Blood pressure 100/50 mm Hg

Respiratory rate 16 breaths, temperature 99.9

Write a SBAR report

Answer 1

ANSWER :

SBAR REPORT :

(S)SITUATION :

• T.N , she is multigravida ,G6P4014 had vaginal delivery 2 hours ago.
• She delivered a healthy male child.

(B)BACKGROUND:

• She is a multigravida G5P4014 who delivered vaginally 2 hours ago.
• Epidural block was given during her labour and delivery.
• Midline episiotomy was givern during the process of delivery.
• Later on admitted in post partum unit for observation.
• She gave birth to a healthy male child.

(A)ASSESSMENT :

• Vital status - BP : 100/50 , it might be low due to epidural effect.
• PR : 120 bpm, as she is multigravida postpartum haemorrhage chances are more which can lead to blood loss in turn results in tachycardia.
• Temperature - 99.9,might be elevated.
• Fundal height - might be enlarged due to multigravida.
• Lochia - might be profuse for multigravida.
• Episiotomy - assess the swelling and discoloration.
• Urinary output -she should void in 6-8 hrs and encourage fluids.
• Bowel elimination - might be sluggish, should avoid straining and advise stool softner if needed.
• Breasts- see for tenderness and engorgement and breastfeeding.
• Perineal pain assessment.
• Assess patients emotional status.

(R)RECOMMENDATIONS :

• Increased risk for postpartum haemorrhage so : a)Continous vitals monitoring is required. b)Examine uterine fundus for atonicity and watch for any excessive vaginal bleeding .
• Pain management for midline episiotomy - Analgesics ,ice ,sitz bath etc
• Advise proper and healthy diet.
• Advise and recommend exclusive breast feeding for baby.
• Advise and counsel regarding family planning surgery.