SBAR Situation: Sandra Thompson is an 80-year-old female who presented to the emergency department with an acute upper g

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SBAR
Situation: Sandra Thompson is an 80-year-old female who
presented to the emergency department with an acute upper
gastrointestinal bleed secondary to a recently diagnosed duodenal
ulcer. She has also been complaining of having to get up several
times during the night to urinate she has a low-grade temperature
of 100.4-100.8 over the past 3 days. This morning she was on the
phone with her daughter and showed signs of confusion to time and
place. Her daughter stopped by to check on her and noticed she
vomited brownish coffee ground material and was pale and
diaphoretic. Sandra's daughter took her to the ED by ambulance.
Background: Ms. Thompson is a widower who lives at home alone,
but has an adult daughter who is a significant support system. She
has no significant cardiac or pulmonary diseases. She has bilateral
osteoarthritis of the knees. One week ago, Ms. Thompson was seen by
her primary care provider because of abdominal pain. At that time,
an endoscopy confirmed a duodenal ulcer, and she was prescribed
Omeprazole 20mg PO daily. The past 3 days, Sandra told her daughter
that she has to get up several times during the night to urinate,
though "not much comes out." She has also complained of chills and
took her temp which was between 100.4-100.6.
She has no known drug allergies and the only prescribed
medications she has are Ibuprofen 600mg TID and Omeprazole 20mg
daily. She is English speaking and a Full Code.
Assessment: Ms. Thompson is alert, but visibly anxious and
displays some intermittent confusion. She is disoriented to time
and situation. Her lungs are clear to auscultation bilaterally. She
is on full telemetry monitoring and is in a sinus tachycardia
rhythm. S1S2 are audible. She is visibly pale, diaphoretic to touch
and her capillary refill is at exactly 3 seconds. Her abdomen is
distended, she has generalized pain to palpation and her bowel
sounds are hypoactive. A NG tube was placed for gastric
decompression upon admission to the ED and it is draining coffee
brown emesis which is guiac positive. She also had an indwelling
foley catheter placed upon arrival, it is draining amber urine. She
has a 20g peripheral IV catheter to her right antecubital and a
triple lumen central line was placed to her right chest wall. Labs
have been sent and results are pending.
Her most recent set of vital signs are as follows: HR 116, BP
106/70, RR 22, Temp 37C and spO2 96% on RA. She is a high fall
risk.