Free SBAR Framework Template
SBAR Framework
Date: September 26, 2050
I. Situation
The patient, Jean Harris, is a 65-year-old male admitted with acute respiratory distress secondary to pneumonia. He is currently on supplemental oxygen and requires continuous monitoring due to fluctuating oxygen saturation levels.
II. Background
Jean Harris has a medical history significant for chronic obstructive pulmonary disease (COPD) and hypertension. He has been treated with bronchodilators and corticosteroids. A chest X-ray revealed bilateral infiltrates, confirming the diagnosis of pneumonia. His current medications include:
|
Medication |
Dosage |
Route |
|---|---|---|
|
Albuterol |
2.5 mg |
Inhalation |
|
Prednisone |
20 mg |
Oral |
|
Amoxicillin |
500 mg |
Oral |
III. Assessment
Upon examination, Jean Harris appears to be in moderate respiratory distress. Vital signs are as follows:
|
Vital Sign |
Value |
|---|---|
|
Blood Pressure |
130/85 mmHg |
|
Heart Rate |
110 bpm |
|
Respiratory Rate |
24 breaths/min |
|
Oxygen Saturation |
88% on 4L O2 |
Auscultation of the lungs reveals diminished breath sounds bilaterally with wheezing. The patient's condition is stable but requires ongoing assessment and intervention.
IV. Recommendation
It is recommended to:
-
Increase supplemental oxygen to 6L via nasal cannula to maintain oxygen saturation above 92%.
-
Administer a nebulized bronchodilator every four hours.
-
Reassess respiratory status every hour and consider an early consult with a pulmonologist if no improvement is noted.
For further inquiries or updates regarding Jean Harris's status, please contact Nurse [Your Name] at [Your Email] or call [Your Company Number].
Thank you for your attention to this matter.
