Free SBAR Nurse Report Template
SBAR Nurse Report
Prepared by: [Your Name], [Your Company Name]
I. Situation
|
Name: |
John Doe |
|
Age: |
67 |
|
Gender: |
Male |
|
Room Number: |
RM 305 |
|
Current Condition: |
Patient presents with acute shortness of breath and chest pain. Condition has deteriorated over the past 24 hours. |
II. Background
|
Medical History |
|
Chronic Obstructive Pulmonary Disease (COPD) |
|
Hypertension |
|
Diabetes Mellitus Type 2 |
|
Recent Changes |
|
Patient was admitted on March 15, 2052, for pneumonia. Recent escalation in respiratory distress noted. |
III. Assessment
Vital Signs
|
Time |
Temperature |
Blood Pressure |
Heart Rate |
Respiratory Rate |
|---|---|---|---|---|
|
08:00 |
101.2°F |
150/90 mmHg |
112 bpm |
28 breaths/min |
|
12:00 |
100.8°F |
145/88 mmHg |
108 bpm |
30 breaths/min |
Observations
-
Increased use of accessory muscles for respiration
-
Persistent cough with yellow sputum
-
Oxygen saturation levels dropping below 90%
IV. Recommendations
Immediate Actions
-
Administer supplemental oxygen
-
Begin nebulizer treatments
-
Notify attending physician for further instructions
Further Monitoring
Continue to monitor vital signs every 4 hours and report any significant changes immediately.
For further information, please contact:
Email: [Your Company Email]
Website: [Your Company Website]
Social Media: [Your Company Social Media]
