Question

B.K. is a 63-year-old woman who is admitted to the step-down unit from the emergency department (ED)
with nausea and vomiting (N/V) and epigastric and left upper quadrant (LUQ) abdominal pain that is
severe, sharp, and boring and radiates through to her mid back. The pain started 24 hours ago and awoke
her in the middle of the night. B.K. is a divorced, retired sales manager who smokes a half-pack of cigarettes
daily. The ED nurse reports that B.K. is anxious and demanding. B.K. denies using alcohol. Her vital
signs (VS) are as follows: 100/70, 97, 30, 100.2° F (37.9° C) (tympanic), Spo2 88% on room air and 92% on
2 L of oxygen by nasal cannula (NC). She is in normal sinus rhythm. She will be admitted to the hospitalist
service. She has no primary care provider (PCP) and has not seen a physician "in years."
The ED nurse giving you the report states that the admitting diagnosis is acute pancreatitis of
unknown etiology. A computed tomography (CT) scan has been ordered, but unfortunately the CT scanner
is down and will not be fixed until morning. However, an ultrasound of the abdomen was performed,
and "no cholelithiasis, gallbladder wall thickening, or choledocholithiasis was seen. The pancreas was not
well visualized due to overlying bowel gas." Admission labs have been drawn; a clean-catch urine specimen
was sent to the lab, and the urine was dark in color.

Please help me write SBAR for this case

Answer 1

SBAR is a communication tool among nurses and it must be used on each occasion of hand over or endorsement of patient to next staff.I In SBAR , S indicates Situation, B for Backgroung , A for Assessment and R for Recommendation.

S( situation)	Ms. B.K / 63years /Female admited to step down unit via ED with diagnosis of acute pancreatitis of unknown etiology.
B( Background)	Patient had complaints of nausea, vomiting, severe epigastric and left upper quadrant pain radiates through to her mid back,pain started 24 hours ago. She smokes half packet of ciggerets daily and has no primary care provider.
A(Assessment)	Vital signs: BP-100/70mmhg, HR -97b/m(normal sinus rhythm), RR -30b/m,Temp-100.2 F (tympanic), SPO2-92% on 2L nasal cannula. Ultrasound abdomen: No cholelithiasis, gall bladder thickening, or choledocholithiasis. Pancreas was not well visualised due to overlying bowel gas. Admission labs, clean catch urine specimen: sent, awaiting for report.
R ( recommendation)	For possible CT abdomen in the morning. To collect lab reports. Evaluate the pain status of the patient. Reduce patient's anxiety.