S–B–A-R

SITUATION

Nurse-to-Nurse report
My name is Avec from John Abbott College. I am the student nurse who took care of Ms.
Kelly today and I would like to give you the end-of-shift report.
BACKGROUND

•Ms. Kelly is a 74 year old white female who came here 3 days ago through the ER.
Admitting Diagnosis was infected diabetic ulcer left foot. She is an insulin dependent
diabetic, and has a history of CHF and COPD. The patient will be discharged tomorrow.

•Her vital signs are within normal limits (BP- 120/80mmHg, temperature – 37, pulse- 84
bpm, respiration- 16). Her lungs are clear. No weight gain since yesterday and no
peripheral edema. Her Fasting BS was 260 but dropped to 120 before lunch. She states
that her blood sugar have been between 200 and 300 for the last 5 days. We called Dr.
Leclerc but he didn’t want Ms. Kelly to be put on sliding scale. Please continue to check
her Blood sugar four times a day and notify the MD if > 300.

“Her wound is a 4x 5x 3 cm to the medial aspect of the left foot. The surrounding tissue is
swollen and red all the way around the edges. We are irrigating with NSS, then covering
with wet-to-dry gauze and securing with Kerlix three times a day. She tolerates the
dressing changes well. Since yesterday the redness has decreased. Also, there is no foul
odor to the drainage anymore. She is on Keflex 400 mg IV three times a day”.

ASSESSMENT

• She lives alone in her house and is financially limited. She states that sometimes she
doesn’t have enough money to buy all her medications thus has not been compliant with
all her medications. She doesn’t know how to do wound care and there is a high risk for
infection. Also, diet is an issue because she does not know how to calculate a 1800 ADA
diet because nobody explained it to her. She doesn’t have enough money to buy healthy
foods suitable for her diet so she prefers whatever is on sale or less costly regardless of its
caloric and nutritional values. She drinks 1L. of regular coke a day because she`s not
aware of its effect on her current health condition.

RECOMMENDATIONS

• We already called the dietician to assess and explain to the patient her nutritional status
and to determine the nutritional treatment plan tailored for Ms. Kelly but he hasn’t called
back yet. Can you please do a follow up call and ask him to come as soon as he can? Dr.
Leclerc is planning on discharging Ms. Kelly tomorrow. I also recommend calling the social
worker. Maybe, Ms. Kelly would be eligible for medication assistance and food allowance.
There is also a need for CLSC for Hospital discharge follow-up and assess patient’s other
health and domestic needs such as cleaning of foot ulcer and changing of dressing,
checking of the drug compliance of the patient, maintenance of personal hygiene and
ensure the regular appointment with the doctor. Do you agree with this plan? Is there
anything that I missed? Please let me know and I would like to hear your suggestions.
Thank you!