SBAR Nursing Report

Prepared by: [Your Name]

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I. Situation

Date: August 27, 2050
Location: [Your Company Address]
Patient Name: Sophia Martinez
Patient ID: 456789
Nurse on Duty: [Your Name]

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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

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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.

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IV. Recommendation

1. Immediate Actions:

   • Continue monitoring vital signs and oxygen saturation every 4 hours.

   • Administer antipyretics as needed for temperature control.

2. Further Monitoring:

   • Reassess lung sounds and sputum production regularly.

   • Monitor blood glucose levels and adjust diabetic management as necessary.

3. Consultation:

   • Schedule a follow-up with the infectious disease specialist to review antibiotics.

   • Consult an endocrinologist for diabetes management during acute illness.

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