Patient Case Study: Application of SBAR in Assessing Epigastric Pain

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Contents
INTRODUCTION.......................................................................................................................................1
SITUATION...............................................................................................................................................1
BACKGROUND.........................................................................................................................................1
ASSESSMENT...........................................................................................................................................2
RECOMMENDATION................................................................................................................................3
REFERENCES............................................................................................................................................4
INTRODUCTION
SBAR is the acronym used to describe situation, background, assessment and
recommendations. It is a communication tool that is widely used by health care professionals
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and paramedics to communicate the condition and case of a patient before handling it to
others (Stewart,2016). The purpose of this tool is to provide easy and non-hierarchal
communication that makes the interaction between professionals viable and prompt(Sowers,
2013).
SITUATION
A 78 years old male patient named Charles Sondergurd was presented to us with the complaint
of epigastric pain that is severe in nature since last 5 days. The patient complains of stabbing
pain in his epigastric region continuing till his back. The pain is severe in nature but does not
worsen on breathing. He also complains of being sweaty, dry mouth and nausea. The patient is
well versed with the nature of pain and accompanying symptoms with it. The pain does not
relieve even on taking medication as described by the patient. He took two panadol yet the
pain could not subside. Rest is only seen as the reliving factor when assessed. The patient is
accompanied by his wife Doris at the hospital.
BACKGROUND
Patient presents history of chest pain since 5 days that has been intermittent in nature. The
chest pain is accompanied by sweating, nausea and loss of sleep. The doctor referred the
patient to the hospital with the assumption of him having angina. Patient is diabetic and also
has past cardiac history. Surgical history reveals no relevant data as patient has not undergone
any surgical procedures in past. Social life involves his life with his wife Doris and they have no
children. He is retired and spends most of his time at home with his wife that restricts any kind
of physical activity in his life. Old age presents various health challenges and old age associated
with diabetes makes a patient to be at high risk of developing cardiac issues. Since Diabetes
leads to narrowing of blood vessels and atherosclerosis and patient is hypertensive, he is at
high risk of cardiac arrest (Sowers, 2013).
ASSESSMENT
On assessing the patient in general and specific context following findings were revealed, the
patient looks exhausted and sweaty, he seems to be not well groomed and personal hygiene is
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low, he seems to be nervous and anxious that might be due to severity of pain. Speech pattern
is slow due to pain but full statements are said and no abnormality found. Expressions on his
face include clear signs of stress and distress. General assessment of patient shows he has red
eyes due to sleep deprivation as explained by severity of pain last night, sweaty and looks
tiered.
We have used a focused assessment plan for assessing the specific condition that is epigastric
pain of the individual as well as comprehensive assessment plan to assess the generalized
condition of the patient (Crisp, Douglas, Rebeiro and Waters,2016).
The vitals when assessed shows temperature is 36.5 ◦C, pulse is 72 per minute, respiration 18
per minute and blood pressure is 150/95 mmHg, patient shows high rise in blood pressure that
may be due to severe pain. Focused pain assessment was done that shows patient has severe
throbbing pain in his epigastric region radiating towards back;the pain is rated to be 7/10 on
the pain scale while doing some physical activity and relieving with rest to 3/10 on the scale.
The psychologicalassessment reveals the person is in his full senses and is able to communicate
well.He presents apology and reasoning for his bad personal hygiene and appearance. He asks
for help and has concern regarding the pain associated with his heart.
Capillary refill normally should be lessthan 3 seconds and when assessed it is normal for the
patient, airway is clear with no breathing sounds and normal breath rate, blood pressure’s
normal range is 120/80 while the patient shows elevated range of 155/95 mmHg (Estes,Calleja,
Theobald & Harvey, 2016).Epigastric pain usually relieves while walking or taking medication
but the pain radiating to back and relieving on rest may indicate angina.
Diabetes, high blood pressure, and pain has made patient exhausted, sleep deprived and
anxious that is responsible for his condition currently and was assessed by the means of
following assessment tools (Rebeiro, Wilson, Scully, & Jack,2017).
RECOMMENDATION
Some goals of care can be developed including
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 Check vitals properly
 Continuous reassessment of vitals and blood pressure specifically
 Apply ice packs for pain relief
 Psychological support with effective communication and interaction with the patient
 Rest can be indicated as it I assessed to be the relieving factor
 Involve family support in the care planning
REFERENCES
 Crisp, J., Douglas, C., Rebeiro, G. and Waters, D., (2016). Potter & Perry's Fundamentals
of Nursing-Australian Version-eBook. Elsevier Health Sciences.
 Estes, M., Calleja, P., Theobald, K., & Harvey, T.,(2016). Health assessment and physical
examination. Cengage Learning.
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 Rebeiro, G., Wilson, D., Scully, N., & Jack, L., (2017) Fundamentals of Nursing Clinical
skilla workbook. (3rd edition) Chatswood NSW: Elseiver
 Sowers, J.R., (2013). Diabetes mellitus and vascular disease. Hypertension, 61(5),
pp.943-947.
 Stewart, K.R., (2016). SBAR, communication, and patient safety: an integrated literature
review.
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