OSCE SBAR
65-year-old male Michael Jones brought to A and E with a bad chest pain that has been going on for 6 hours and has gotten worse the past hours.
Past medical history. No pass medical history
Medication; no medication
Allergies. penicillin
Family history- Mother died of cancer at age 58
Social history. -patient is into farming as occupation, don’t drink and don’t smoke
Patient also suffers from low mood.
Airways- patient talking clearly and managing own secretion
Breathing- equal bilateral entry, Sat 95 percent, RR 24
Circulation -Pulse 115, BP 184/106, Capillary refill 3 sec
D-AVPU patient was alert, BM 5.6 pupil equal and reacting to light, temperature 37.2
Exposure-sweety and clammy
ALL LEARNING OUTCOME NEEDS TO BE MET IN THE ESSAY!!!
LO1 Assimilate knowledge and evidence to undertake a full and accurate holistic nursing assessment, as the basis of care planning across the life span.
LO2 Demonstrate and apply knowledge of commonly encountered mental, physical, behavioural and cognitive conditions and symptoms across the lifespan, including the ability to recognize care needs and respond appropriately to changes, distress and deterioration.
LO3 Demonstrate appropriate communication skills to support all people to make informed choices throughout the shared assessment, care planning and care coordination processes, including transfer and discharge procedures.
LO4 Effectively assess a person’s capacity to make decisions about their care and to give or withhold consent and justify your decisions made about care for people who do not have capacity.
LO5 Critically review and interpret clinical measurements and assessment findings to make justifiable clinical decisions and appropriate referrals and escalations.
LO6 Accurately document your clinical findings and communicate a proposed plan of care, verbally and in writing.
