SBAR Reporting

Date: September 26, 2050

I. Situation

• Patient Name: Malcolm Raynor

• Age: 72 years

• Gender: Male

• Admitting Diagnosis: Chronic Obstructive Pulmonary Disease (COPD) Exacerbation

• Current Status: Stable but needs more effort to breathe; on supplemental oxygen.

II. Background

Mr. Raynor was admitted to [Your Company Name] on September 24, 2050, after presenting with increased shortness of breath and a productive cough for the past three days. His medical history includes:

• COPD (moderate severity)

• Hypertension

• Coronary Artery Disease

He has a history of multiple exacerbations requiring hospitalization. The patient is currently on a home regimen of a long-acting beta-agonist and inhaled corticosteroids. He also received nebulizer treatments upon admission.

III. Assessment

• Vital Signs:

  • BP: 140/90 mmHg

  • HR: 88 bpm

  • RR: 22 breaths/min

  • O2 Sat: 92% on 2L nasal cannula

• Respiratory Assessment:

  • Lung sounds: Wheezes and rhonchi bilaterally

  • Accessory muscle use observed; patient appears fatigued.

• Laboratory Results:

  • Arterial Blood Gas (ABG): pH 7.32, pCO2 55 mmHg, pO2 70 mmHg

The patient reports moderate dyspnea, rated 6/10 on the pain scale, which improves with increased oxygen support.

IV. Recommendation

1. Continue to monitor vital signs and oxygen saturation closely.

2. Increase supplemental oxygen to maintain O2 saturation above 94%.

3. Administer bronchodilator treatments every four hours as needed.

4. Schedule a follow-up chest X-ray to evaluate for any potential complications.

5. Educate the patient on proper inhaler techniques and the importance of adhering to prescribed medications.

Next Shift Handoff

• Nurse: Philip Mitchell

• Contact: (222) 555-7777

Hospital Information

• Hospital Name: [Your Company Name]

• Address: [Your Company Address]

• Email: [Your Company Email]

• Phone Number: [Your Company Number]

Your Information

• Your Name: [Your Name]

• Your Email: [Your Email]

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