Free SBAR Nursing Report Template
SBAR Nursing Report
Prepared by: [Your Name]
I. Situation
Date: August 27, 2050
Location: [Your Company Address]
Patient Name: Sophia Martinez
Patient ID: 456789
Nurse on Duty: [Your Name]
II. Background
Berta Flatley, a 72-year-old female, was admitted on August 25, 2050, with a diagnosis of pneumonia. She has a history of asthma and diabetes. Sophia is currently receiving broad-spectrum antibiotics and is on supplemental oxygen.
Recent Vital Signs:
|
Vital Sign |
Measurement |
|---|---|
|
Blood Pressure |
125/80 mmHg |
|
Heart Rate |
88 bpm |
|
Respiratory Rate |
20 breaths/min |
|
Temperature |
99.1°F (37.3°C) |
Current Treatments:
|
Treatment |
Details |
|---|---|
|
Antibiotics |
Ceftriaxone 1g IV |
|
Oxygen Therapy |
2 L/min via nasal cannula |
|
Inhalers |
Albuterol 90 mcg, 2 puffs every 4 hours |
III. Assessment
Berta’s condition is showing gradual improvement with the current treatment. Her fever has reduced and oxygen saturation is stable. However, she reports persistent coughing and mild chest discomfort. There is no evidence of respiratory distress at this time, but her blood glucose levels have been slightly elevated.
IV. Recommendation
-
Immediate Actions:
-
Continue monitoring vital signs and oxygen saturation every 4 hours.
-
Administer antipyretics as needed for temperature control.
-
-
Further Monitoring:
-
Reassess lung sounds and sputum production regularly.
-
Monitor blood glucose levels and adjust diabetic management as necessary.
-
-
Consultation:
-
Schedule a follow-up with the infectious disease specialist to review antibiotics.
-
Consult an endocrinologist for diabetes management during acute illness.
-
