SBAR Report: Post-Operative Complications

Situation

Patient is experiencing increased pain and erythema around the surgical site, with a temperature of 101.5°F 12 hours post-operatively.

Background

The patient underwent an appendectomy on October 14, 2024, with no immediate intraoperative complications. The patient was initially stable post-surgery, with standard vitals. There is a history of mild hypertension, managed with lisinopril.

Assessment

Clinical signs suggest potential surgical site infection or other post-operative complications. The patient is also reporting nausea and discomfort that is not being managed effectively by current pain medication regimen.

Recommendation

Request an immediate evaluation by the surgical team to assess for potential infection. Consider adjusting pain management, and advise initiating an empirical antibiotic therapy while awaiting further instructions. Monitor vital signs closely and prepare for potential imaging studies as ordered by the surgical team.