Documentation Simulation

SBAR reporting is an important tool to learn in nursing. It helps to ensure smooth communication between healthcare providers, which helps to decrease the incidences of miscommunication leading to errors and ultimately to patients not receiving appropriate care.

Here is a great resource for learning about SBAR reporting, take a few minutes to review it before moving on to the next part of this simulation: https://drive.google.com/file/d/1ghioDQ6ec5wNjDV7HSVoDXrWLWB9XK6I/view?usp=sharing

Simulation

You are an RPN student working in your local emergency room, assigned to the fast-track department. Joey is a 41-year-old man who comes in with acute low back pain. He states that he did some heavy lifting yesterday, went to bed with a mild backache, and awoke this morning with terrible back pain, which he rates as a 10 on a scale of 1 to 10. He admits to having had a similar episode of back pain years ago “after I lifted something heavy at work.” Joey has a medical history of peptic ulcer disease related to non-steroidal anti-inflammatory drug (NSAID) use. He is 6 feet (183 cm) tall, weighs 265 pounds (120 kg), and has a prominent “potbelly.” The doctor ordered a back x-ray and blood work. The lab work is back with no abnormalities and the radiologist called to say that there was nothing abnormal on the x-ray.

You discuss this case with your preceptor, who supports calling the physician and asking for a prescription that will help with a muscle strain.

Use the following SBAR tool to document what you need to say to the physician.

Joey is given a prescription from the physician for prescriptions for cyclobenzaprine (Flexeril) 10 mg tid for 3 days only, and celecoxib (Celebrex) 100 mg/day for 3 months.

He is also told to use heat applications to the lower back for 20 to 30 minutes four times a day (using moist heat from heat packs or hot towels), no twisting or unnecessary bending, and no lifting more than 10 pounds (4.5 kg). Joey is also instructed to rest his back for 1 or 2 days, getting up only now and then to move around to relieve muscle spasms in his back and strengthen his back muscles.

The physician also gives him a written letter to stay off work for 5 days and, when he returns to work, specifying the limitation of lifting no more than 10 pounds (4.5 kg) for 3 months. He is instructed to contact his primary care provider if the pain gets worse.

Use the following documentation tool to document all your care for this patient.