Medical SBAR
Medical SBAR
Prepared by: Nurse [Your Name]
I. Situation
Date: August 27, 2050
Time: 08:15 AM
Patient Name: John Doe
Patient ID: 123456789
Location: Room 304, [Your Company Name]
Summary of Situation:
Mr. John Doe, a 65-year-old male admitted with a diagnosis of congestive heart failure, has experienced a sudden and significant change in his condition. At 07:45 AM, the patient developed acute shortness of breath and a persistent cough.
II. Background
Relevant Medical History:
-
Primary Diagnosis: Congestive Heart Failure
-
Comorbidities: Hypertension, Type 2 Diabetes
-
Recent Procedures: None in the past 24 hours
Current Medications:
|
Medication |
Dosage |
Frequency |
|---|---|---|
|
Lasix |
40 mg |
Daily |
|
Lisinopril |
10 mg |
Daily |
|
Metformin |
500 mg |
Twice Daily |
Recent Vital Signs:
|
Vital Sign |
Value |
Time |
|---|---|---|
|
Blood Pressure |
150/95 mmHg |
07:30 AM |
|
Heart Rate |
88 bpm |
07:30 AM |
|
Respiratory Rate |
22 breaths/min |
07:30 AM |
|
Temperature |
98.7°F |
07:30 AM |
III. Assessment
Clinical Assessment:
-
Physical Examination: The patient presents with bilateral crackles on lung auscultation and an increased respiratory rate. The patient appears dyspneic and is using accessory muscles to breathe.
-
Changes in Condition: Notable decrease in oxygen saturation levels (SpO2 88% on room air), which has not improved with supplemental oxygen (2 L/min via nasal cannula).
-
Current Concerns: Possible exacerbation of heart failure or an underlying respiratory infection. Immediate intervention is required.
IV. Recommendation
Suggested Actions:
-
Immediate Evaluation: Request urgent evaluation by a cardiologist to assess the need for advanced cardiac intervention.
-
Diagnostic Tests: Order chest X-ray and arterial blood gases (ABG) to determine the extent of pulmonary and cardiac involvement.
-
Treatment Adjustments: Consider adjusting diuretics and initiating broad-spectrum antibiotics if a respiratory infection is suspected.
-
Monitoring: Continuous monitoring of vital signs and oxygen saturation levels. Consider placing the patient on a higher-flow oxygen device if necessary.
