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]
Report Templates @ Template.net
