Question

You are the nurse in a walk-in clinic. A.P. is being seen this morning for a 2-day history of diffuse, severe
abdominal pain. She has complaints of nausea without vomiting; she denies vaginal bleeding or discharge.
A.P. reports having unprotected sex with several partners recently, two of whom had penile discharge.
Her last menstrual period ended 3 days ago. She has no known drug allergies and denies previous
medical or psychiatric problems. Vital signs are 108/60, 110, 20, 100.6 ° F (38.1 ° C). Physical examination
reveals that her abdomen is very tender. The slightest touch of her abdomen causes her to wince with
pain. Bowel sounds are normal. Pelvic examination reveals purulent material pooled in the vaginal vault,
which appears to be coming from the cervix. A sample of the vaginal drainage is obtained and sent for
culture. The result of a pregnancy test is negative; a rapid diagnostic test for chlamydial infection has a
positive result. The physician has the option of treating A.P. by one of two different methods. First, the physician could
prescribe treatment over a period of 1 week. A.P. would be given the first dose of doxycycline (Monodox)
100 mg PO, and then she would be prescribed the same dose to be taken PO bid for 7 days. Second, the
physician could prescribe a one-time dose of azithromycin (Zithromax) 1 g PO, which could be administered
in the clinic. A.P. returns to the clinic in 1 week for her HIV test results, which are negative. Her culture results confirm
the diagnosis of chlamydial infection.

Write a end of shift SBAR report.

Answer 1

sBAR stands for sutuation, background, acessment and recommendations.

Situation:

In motning a patient named A.P joined in the hospital with complaints of abdominal pain and nausea. On examination :

• BP: 108/60 mmHg
• PR: 110bpm
• RR: 20 cpm
• Temp: 100.6°F
• P/A: tender. Slight touch can cause her wince with pain
• Bowel : normal
• Pelvic : purulent material pooled in the vagina.

Laboratory data revealed

• Pregnancy report : negative
• Chalmydia : positive
• HIV : negative

Treatment options :

• Doxycycline od followed by bd upto seven days.
• Azithromycim 1 gm single dose.

Background::

He had sex with different patners one of them had penial discharge. No psychiatry problems. No vaginal bleeding. No drug allergies. Her menstrual cycle ended 3 days ago.

Acessment:

Based on the subjective and objective evidence she is suffering from chalmydial infection.

Recommendations:

• Practice safe sex. Use condoms during sex.
• Dont ususe any over the counter medications.
• Complete the antibiotic course as requested by the physician. Because incomplete course can cause bacterial resistance.
• Clean the vaginal region regularly.
• Try to avoid sex until the infection is cured.