Sample SBAR for a 78 year old female with spinal Neoplasm. She came in with back pain, she had fone an MRI previously that shows a mass in her spine . She had a bilateral L4-L5 posterior fusion laminectomy to remove her epidural mass. She is suppose to lay flat. She has on a Nasal canula with 1 liter of oxygen., fall risk, has allergies- shellfish, amlodipine, codeine, lactose, mould and smuts, morphine and predisone. Patient has a history ofhtn, afib, and breast cancer, full code, dural tear, alert times 3 forgetful. Vomit last night after getting regland, headache and a foley.
I am reporting on a 78-year-old female patient who was admitted with a diagnosis of spinal neoplasm. She presented with severe back pain and had a recent MRI confirming the presence of a spinal mass. The patient underwent a bilateral L4-L5 posterior fusion laminectomy to remove the epidural mass and is currently required to remain in a supine position. She is receiving 1 liter of oxygen through a nasal cannula. The patient is at risk for falls, and she has multiple allergies, including shellfish, amlodipine, codeine, lactose, mold and smuts, morphine, and prednisone. She has a medical history of hypertension, atrial fibrillation, and breast cancer. The patient is a full code, experienced a dural tear during surgery, is alert and oriented times 3, although she is somewhat forgetful. She vomited last night after receiving Reglan, and she reports having a headache. Additionally, the patient has a Foley catheter in place.
The patient’s back pain led to the discovery of a spinal mass, which necessitated surgery. Her postoperative course has been complicated by vomiting, a headache, and the need for a Foley catheter. She has a history of allergies and comorbidities such as hypertension, atrial fibrillation, and breast cancer. The dural tear is a surgical complication that requires close monitoring.
The patient is alert and oriented times 3, although she appears to be somewhat forgetful. Her vital signs are stable, with the assistance of 1 liter of oxygen via a nasal cannula. She is at risk for falls due to postoperative precautions. The presence of a Foley catheter indicates a need for bladder management.
Continue monitoring vital signs, oxygen saturation, and neurological status.
Assess the patient’s headache and provide appropriate pain management.
Review the patient’s allergies to ensure that medications and interventions are safe.
Maintain fall precautions due to the postoperative requirement of a supine position.
Monitor the Foley catheter and assess for urinary output.
Communicate with the healthcare team regarding the patient’s condition and complications to ensure prompt evaluation and management.
This SBAR report summarizes the patient’s situation, background, assessment, and recommendations, facilitating effective communication and coordination of care for the 78-year-old female with a spinal neoplasm.
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