SBAR Nurse Report

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