SBAR
SBAR
Prepared by: Nurse [Your Name]
Date: October 5, 2053
Situation:
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The patient, Jake Willms, a 65-year-old male, has shown signs of deterioration over the last few hours.
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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:
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Admitted three days ago with community-acquired pneumonia.
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History of hypertension and type 2 diabetes.
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Receiving IV antibiotics and supportive care.
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Initial improvement was noted; however, deterioration has occurred in the last 6 hours.
Assessment:
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Vital signs suggest hemodynamic instability and potential infection progression.
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Symptoms: increased shortness of breath, decreased urine output (< 30 mL/hr), altered mental status (confusion, disorientation).
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Physical findings: bilateral crackles on lung auscultation, increased work of breathing.
Recommendation:
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Immediate review and possible intervention by the attending physician.
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Consider ordering: repeat chest X-rays, arterial blood gases (ABGs), and blood cultures.
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Recommend escalation to the Intensive Care Unit (ICU) for closer monitoring and advanced support.
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Evaluate the need for vasopressors if there is no response to fluid resuscitation.
