Running head: NURS 416 SBAR 1 Nursing 416 SBAR Assignment October 27, 2016 NURS 416 SBAR 2 (S) Situation: My name is. I am a nursing student from Bowie State University. I am caring for a 5-year-old female named E.M who weighs 20.5kg. She has diarrhea. (B) Background: E.M has no known allergies or past surgeries, and she is full code. She has a 3day history of vomiting and diarrhea with signs of dehydration. She is currently receiving and IV of Normal Saline bolus 400ml (20ml/kg). (A) Assessment: E. M’s functional status is appropriate for age. She vomits and has loose stools. She seemed irritable, pale, and lethargic, which are related to her dehydration. Additionally, she has dry skin and mucous membrane, poor skin turgor, increased blood pressure and pain. Her vital signs were as follows: RR- 26, P- 118, BP- 116/78, T- 99.6.0, and Pain level of 7/10 in the abdomen. She was alert and oriented x3. Facial movements are symmetrical. Shoulders move symmetrically. Heart rate was at regular rate and rhythm. Pulse site was palpable and located at the radial site. Capillary refill was less than 2 second. Lung sounds were clear bilaterally.

Chest expansion and size were symmetrical. The abdominal shape was round and symmetrical. Abdomen was soft to touch. Bowel sounds were hyperactive. (R) Recommendation: I would recommend rehydration (with oral rehydration solution like Pedialyte), plenty of rest, avoiding BRAT (Banana diet, Rice, Applesauce, and Toast) diet, high protein diet, acetaminophen for pain, and applying cream on the body to avoid skin bread. I would also suggest cleaning the toy areas, clip long nails, avoiding nail biting or thumb sucking, and frequent showering. Therefore, proper adherence to these suggestions would lead to adequate fluid volume. NURS 416 SBAR 3 SBAR Note Grading Criteria Student Name:____________________ Date:__________________ Grade__________% (____total points received/2.5) Comments Situation: Provide a concise statement of the problem. 0.60% Background: State the pertinent and brief information related to the situation. 0.30% Assessment: Summarize situation and background. Explained what is going on with patient with appropriate assessment data. 1% Recommendation: Describe/Explain what action requested/recommended 0.50 Grammar: Correct grammar, spelling, clear concise data, 0.10 Total 2.5% Points Received SBAR Note Grading Rubric Student Name:____________________ Date:__________________ Grade__________% (____total points received/5) Comments Situation: Provide a concise statement of the problem. 1.2% Background: State the pertinent and brief information related to the situation. 0.60% Assessment: Summarize situation and background. Explained what is going on with patient with appropriate assessment data. 2% Recommendation: Describe/Explain what action requested/recommended 1.0% Grammar: Correct grammar, spelling, clear concise data, 0.20 Total 5% Points Received …Nursing Pediatrics SBAR Documentation Essay