Department of Nursing
S-BAR Grading Rubric
Pathophysiology of admitting diagnosis (please attach on separate page)
Diagnostic procedures/ Laboratory tests
Medication cards (please attach)
s i t u a t i o n
Date of Care: 5/9/14 PT: (initials ) Mr. S
Aqe: Early 80’s Sex: M
Diaqnosis: Gastric Carcinoma
Allergies: NKA Height/ Wt:: (Latest since admit)
170.18cm and 105.91kg
Code Status: Full
Psvchosocial: Has full support from family whom will assist in post discharge care. He is worried about how the pain will be once he gets home.
Attending Physician: (initials)
Consultinq Phvsicians: (specialties)
Shift Goals: Patient will have pain of less than or equal to 4 out of ten and be able to tolerate food during shift.
B a c k g r o u n d Medical History: Arthritis, CHF, dementia, depression, diabetes mellitus, gastritis, GERD, GI bleed, Hyperlipidemia, Hypertension
Surgical History: Cholecystectomy
Risk for Falls
MRSA Screen Complete: Y N NA
Vaccinations: (Vaccine hx and admins)
Core Measures: SCIP core measures set
Activity: Ambulatory with assistance.
s s e s s m e n t
Neurological function : Awake alert and orientated X3. Speech is clear, fluid mentation, and fine and gross motor movements are intact.
Pain: (include detailed pain assessment)
Hydromorphone 1mg Q2H PRN IV
Cardiac Function: Regular rate and rhythm, s1 murmur noted. Cap refill is less than 3 seconds and apical pulse is 91 BPM
O2=97% on Room air
Apical Pulse: 91 bpm
VTE Prophylaxis: Only SEDS, no anticoagulants due to active bleeding.
IV Access/ IV Solution: Right subclavian Line IV amino acids 1920ml Bedtime
Antibiotics: pipercillin 3.375 gm Q8H IV
Respiratory Function: Lung sounds clear and present and equal bilaterally, no sign of distress or use of accessory muscles. No mucous or cough noted.
O2sat: 97% on Room air
Elimination Gl: last BM was the night before, formed soft and green in color.
Gl Propylaxis: None currently.
Diet: Clear liquid diet
Supplements: None during shift.
Skin: Warm, Dry, No sign of bruising, Skin turgor is less than 1 second. Incision site is approximated, staples intact, slight swelling, no redness, slight tenderness to palpation. JP drain in place, intact no sign of redness or swelling. Drain contents are serosanguinous.
Elimination GU: Foley Catheter. Clear yellow 800ML
No odors noted.
Intake and Output: See attached page for 24 hour report
Restraints: (Type, ordered / renewed)
R e c o m m e n d a t i o n Labs results (Last 24 hours)
Include normal range and identify if low or high
See attached page
Blood Glucose: (Latest 4)
May 8th 2014
Glucose accucheck order:
Q6H before meals and at bedtime.
Insulin coverage order: Insulin Human Lispro Mild Scale
For Blood sugar:
121-150= 0 units
151-200= 2 units
201-250= 4 units
251-300= 6 units
301-350= 8 units
351-400= 10 units
>400= CALL MD
PRN Med. Use: (Current shift)
None during shift.
Select Orders: (ST, OT, PT, EEG, EKG, Echo, MRI, CT) None during Shift
Laboratory/ Radiology/ Respiratory Therapy Orders: None
Diagnostic Test results (during hospitalization)
EKG: Within normal limits, no previous CAD
Echo: Left ventricular ejection fraction is 45%
24 Hour I&O
“The early stages…