I need a step by step SBAR for this patient Baby Z. is 3 weeks old infant in NIC

ID: 138916 • Letter: I

Question

I need a step by step SBAR for this patient Baby Z. is 3 weeks old infant in NICU, nursery 2. He was at 27 weeks gestation when delivered. He has been progressing well after a short period of CPAP and remains in 24% flow support. He is receiving continuous tube feedings. He has demonstrated a steady weight increase. For the first time today, he has had a couple of episodes of apnea. When Sue, the evening nurse, came on and did her assessment she noted he was tachypneic with a respiratory rate of 75. As she was documenting her assessment, Baby Z. had a bradycardia episode and his oxygen saturation decreased to 75. His heart rate returned to 130 with stimulation and Sue increased the oxygen to 28%. He also had some regurgitation of formula. His muscle tone is diminished and his coloring is mottled. She listened to his breath sounds and noted that they were equal and clear. His abdomen is soft and not distended. The day nurse reported that he had slept a lot today and his mother felt he wasn’t as alert as usual.

Explanation / Answer

SBAR means Situation- what is going with thepatient,

Background-What is the clinical background

Assessment-What do i think the problem is

Recommendation-What would i do to correct it

My name is Sue,I am calling from NICU. Who am i, speaking to?

Iam calling about Baby boy who is 3 weeks old.

I am calling because the baby is tachypneic,skin is mottled,regurgitated the formula ,muscle tone is diminished,bradycardia episode,oxygen saturation dipped to 75%

The baby was admitted because of very low birth weight.

Gestation-27 weeks Weight-not given.

Born via C/S NSVD -Not given Forceps-NA Ventouse NA Apgars -not given.

Maternal history -Not given HIV Y/N=NA

Problem list

Ventillation/O2- 24% flow support Intubated- CPAP- short period Nasal cannula not given.

Medications -Not given

Test results -Not given.

Vital signs

Airway/Breathing-75

Circulation-130HR

Temperature-Not given

blood glucose-not given

BP-not given

Oxygen saturation-75%.

I have already increased the oxygen level by 28%,heart rate decreased to 75 which returned back to 130 with stimulation.

How often should i do observations?

When shall i call you backif there is no improveent?

Can i repeat the plan back to you?

Situation