Healthcare SBAR

I. Situation

Patient:

Jane Doe

Date of Admission:

August 25, 2050

Diagnosis:

Chronic Obstructive Pulmonary Disease (COPD)

Current Status:

Jane Doe has been stable but requires continuous oxygen therapy and regular medication adjustments. She has recently been experiencing increased shortness of breath and a slight fever.

II. Background

Medical History:

Condition	Details
COPD	Diagnosed in 2020, managed with inhalers and steroids
Hypertension	Managed with medication
Diabetes Mellitus	Type 2, controlled with oral medication

Recent Treatments:

Oxygen Therapy: Administered via nasal cannula, 2 liters per minute
Medication: Inhaled corticosteroids and bronchodilators; recent dose adjustment due to worsening symptoms

Recent Lab Results:

Chest X-ray: Showed mild bilateral infiltrates
Blood Work: Elevated white blood cell count

III. Assessment

Jane Doe's condition is stable but requires monitoring and potential adjustment of her treatment plan. She has exhibited increased respiratory distress and fever, which may indicate an exacerbation of COPD or an infection. Immediate attention is needed to evaluate these symptoms and adjust her care plan accordingly.

IV. Recommendation

Immediate Actions:
- Increase oxygen flow rate to 3 liters per minute.
- Administer a dose of antibiotic as per the protocol to address possible infection.
- Arrange for a follow-up chest X-ray and blood work in 24 hours.
Follow-Up:
- Monitor Jane’s response to the increased oxygen and medication adjustments.
- Review lab results once available and adjust the treatment plan as necessary.
- Ensure that Jane receives education on recognizing signs of worsening symptoms.