SBAR for Nurses

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I. Situation

Date: August 27, 2050
Location: [Your Company Address]
Patient Name: Jane Doe
Patient ID: 123456
Nurse on Duty: [Your Name]

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II. Background

Jane Doe, a 54-year-old female, was admitted to our facility on August 26, 2050, with symptoms of acute respiratory distress and a history of chronic obstructive pulmonary disease (COPD). She has been receiving oxygen therapy and nebulized medications. Her medical history also includes hypertension and type 2 diabetes.

Recent Vital Signs:

Vital Sign	Measurement
Blood Pressure	140/85 mmHg
Heart Rate	92 bpm
Respiratory Rate	22 breaths/min
Temperature	98.6°F (37°C)

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III. Assessment

The patient’s respiratory distress has improved slightly with current treatment. However, her oxygen saturation levels are fluctuating between 88-92%, which is below the desired range. Jane appears to be increasingly anxious and is experiencing occasional bouts of confusion. There are no signs of immediate distress or new acute symptoms.

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IV. Recommendation

1. Immediate Actions:

   • Increase the oxygen flow rate and monitor saturation closely.

   • Administer a calming medication as per the physician’s protocol to manage anxiety and confusion.

2. Further Monitoring:

   • Continue to assess vital signs every 2 hours and document any changes.

   • Re-evaluate the need for additional respiratory therapies or interventions based on patient response.

3. Consultation:

   • Request a consultation with the pulmonologist for a possible adjustment to the treatment plan.

   • Schedule a meeting with the patient’s primary care physician for a comprehensive review.

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Prepared by: [Your Name]

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