OASIS Alert

Published on Wed Feb 05, 2014 PDF

Focus on the result you want before you contact the physician.

If you’re struggling with getting a speedy response from the physician when your patient experiences heart failure symptoms, a targeted SBAR may be just the remedy. This form from Mary Narayan, MSN, RN, HHCNS-BC, COS-C, with Narayan Associates in Vienna, Va. will help you to present the situation clearly and concisely so you can speed things along.

SBAR Communication about
Exacerbation of Heart Failure

Situation:

• Dr. (name), this is (your name, discipline) from (name of your home health agency).
  
• I am calling about (patient’s name), who is showing signs of fluid overload.
  

Background: (Review medical record, Medication Profile, last visit notes, labs, etc.)

•  Patient’s age ______
•  Primary diagnoses: HF Stage ____; other primary/pertinent diagnoses
•  Recent important events. Examples include:

oAdmitted to home care on (date) for (reason for home care).

oDischarged from the hospital on (date) after being treated for (reason for hospitalization).

oReports did not take diuretic/follow low-sodium diet due to forgetfulness and no caregiver.

oPatient has been hospitalized for HF 3 times in past 2 months.

• DNR status if applicable.

Assessment: (Only report primary/abnormal/pertinent data)

• Patient’s current symptoms:

• SOB  DOE  Orthopnea  Confusion  Fatigue  Angina  Chest tightness 
• Other pertinent symptoms_______________________________________________
• When did symptoms develop? __________
• How severe are symptoms? ______________

• Physical assessment:

•  Vital signs: Pulse ____ RR _____ BP _________ O2 sat _____
•  Current weight _______ Weight gain _____ lbs in ______ days.
•  Extra heart sounds (S3, S4, gallop) 
•  Lung sounds: Fine crackles (rales)  Location: __________________________
•  Jugular vein distension  Peripheral edema: 1+ 2+ 3+ 4+
• Abdominal girth ______ in/cm which is an increase of _______ in/cm since ___________
• Urine color/output: _____________________________________________
• Diuretic medication(s) available: __________________ Is rescue drug (e.g. IVP furosemide) available?
• Have available: Medication Profile, allergies and phone number of pharmacy.

• Analysis:

• Patient seems to be having an acute heart failure exacerbation which we may be able to resolve at home, without rehospitalization.

Recommendation: Examples include

• To avoid rehospitalization, should the diuretic be increased to try to resolve the problem?
• Would you like to double the diuretic for 3 days, which worked last time for the patient?
• Would you like to order IV push furosemide to see if we can diuresis patient at home? I can visit on a daily basis for 2-3 days to administer additional doses and assure the symptoms resolve?
• Should I follow up diuretic therapy with labs in a couple of days? Electrolytes? BUN? Creatinine?
• Could we refer to MSW to assist family to determine caregiving options related to diet and med administration needs?
• Since patient has end-stage HF and patient does not want to go back to hospital, could we have orders for a DNR and referral to palliative/hospice care?