SBAR

Prepared by: Nurse [Your Name]
Date: October 5, 2053

Situation:

• The patient, Jake Willms, a 65-year-old male, has shown signs of deterioration over the last few hours.

• Current vital signs: Blood Pressure 90/60 mmHg (down from 120/80 mmHg), Heart Rate 110 bpm (up from 85 bpm), Respiratory Rate 28 breaths per minute (up from 18 breaths per minute), Temperature 101.2°F.

Background:

• Admitted three days ago with community-acquired pneumonia.

• History of hypertension and type 2 diabetes.

• Receiving IV antibiotics and supportive care.

• Initial improvement was noted; however, deterioration has occurred in the last 6 hours.

Assessment:

• Vital signs suggest hemodynamic instability and potential infection progression.

• Symptoms: increased shortness of breath, decreased urine output (< 30 mL/hr), altered mental status (confusion, disorientation).

• Physical findings: bilateral crackles on lung auscultation, increased work of breathing.

Recommendation:

• Immediate review and possible intervention by the attending physician.

• Consider ordering: repeat chest X-rays, arterial blood gases (ABGs), and blood cultures.

• Recommend escalation to the Intensive Care Unit (ICU) for closer monitoring and advanced support.

• Evaluate the need for vasopressors if there is no response to fluid resuscitation.

SBAR Templates @ Template.net