Question

Three-week-old J.T. and her parents arrive at the cardiac cath lab for her cardiac catheterization. She was
born at term with Down syndrome and her pediatrician is concerned because of lack of weight gain and
poor feeding. You are getting her and her parents prepared for the procedure. After the catheterization, J.T. returns to the unit in a crib. The orders shown in the chart have been written. Chart View
Physician's Orders
Daily weights: Current weight 4 kg
Strict intake and output
O2 per nasal cannula as needed to maintain O2 saturation greater than 93%
VS every 15 minutes × 4, then every 1 hour × 4, then every 4 hours
Digoxin (Lanoxin) 60 mcg PO now, then 20 mcg PO every 12 hours
Furosemide (Lasix) 4 mg PO now, then 4 mg PO every 12 hours

You administer the ordered medication and proceed with your assessment. You note the following serum metabolic panel results for J.T.
Chart View
Laboratory Results
Glucose 85 mg/dL
Calcium 9.1 mg/dL
Sodium 142 mEq/L
Potassium 3.3 mEq/L
Chloride 101 mEq/L

The cardiologist consults with the family, and it is decided that J.T. will be discharged to home the
following day with medications and close monitoring. J.T. will return in several months for surgical
repair of the VSD.

Write a end of shift SBAR report.

Answer 1

SBAR report

SBAR ( Situation, Background,Assessment and Recommendation) is a very useful method of reporting especially for Physicians and Nurses . It can used in shift reports and in staff rounds.

Endshift Report: SBAR of Baby JT:

Situation:

Name of the patient: Baby JT, 3 months old

Admission Date and purpose: ( Date) Admitted to Cathlab, after the Consultation with Paediatrician , for Cardiac Catheterization .

Status: The procedure of Cardiac Catheterization done and the patient is about to discharge on tomorrow ( following day).

She will be admitted within few months for the surgical repair of VSD.

Background: Baby JT was a full term baby, but born with Down Syndrome . At the third month , the parents of JT , brought her for Consultation. Pardiatrcian ordered for a Cardiac Catheterization, due to her poor feeding and failure in weight gain. Cardiac Catheterization revealed that she is suffering with Ventricular Septal Defect ( VSD).

Current medications: Digoxin ( 60 mcg , first dose, 20 mcg PO every 12 hrs)

and Furosemide ( 4 mg PO every 12 hr)

Assessment:

Current body weight: 4 kg

The baby is on Oxygenation

The recent Serum Metabolic values for Calcium, Sodium, Potassium, chloride are found satisfactory and within normal limits.

Recommendation:

* Counselling of parents including the health education on management of baby with a congenital heart disease and the importance of the surgical repair.

* Warn the parents about danger signs, like Cyanosis and instruct them to immediately report to Paediatrician.

* Frequent checking of serum - Digoxin level to prevent Digoxin toxicity in child

* Frequent lab monitoring of electrolyte, especially Potassium.