Nursing SBAR
Prepared by: [Your Name], RN
I. Situation
Patient: Elisa West
Age: 65
Gender: Female
Date: August 27, 2050
Location: [Your Company Name], Floor 3, Room 204
Reason for Contact: Acute onset of severe chest pain
Summary:
Elisa West, a 65-year-old female, presented with acute chest pain that began approximately 30 minutes ago. The patient describes the pain as a "crushing" sensation radiating to the left arm and jaw. Her vital signs are currently unstable, with a blood pressure of 88/56 mmHg and a heart rate of 120 bpm.
II. Background
Medical History:
Hypertension
Type 2 Diabetes Mellitus
Hyperlipidemia
No known allergies
Current Medications:
Medication | Dosage | Frequency |
|---|
Lisinopril | 10 mg | Daily |
Metformin | 500 mg | Twice daily |
Atorvastatin | 20 mg | Daily |
Previous Interventions:
The patient was last seen by her primary care physician two weeks ago for routine follow-up with no significant issues reported.
Recent labs indicated slightly elevated glucose levels, but no acute concerns were noted.
III. Assessment
Physical Exam Findings:
Heart Rate: 120 bpm, irregular
Blood Pressure: 88/56 mmHg
Respiratory Rate: 22 breaths per minute
Temperature: 98.7°F (37.1°C)
Oxygen Saturation: 92% on room air
Clinical Impression: The patient’s symptoms are highly suggestive of an acute myocardial infarction (MI). The instability in vital signs, combined with the description of pain and associated symptoms, warrants immediate intervention.
Risk Factors:
IV. Recommendation
Immediate Actions Required:
Cardiac Monitoring: Initiate continuous cardiac telemetry monitoring to assess for arrhythmias and ST elevation.
Medication Administration: Administer nitroglycerin sublingually and prepare for potential thrombolytic therapy as per protocol.
Consultation: Urgent cardiology consultation is needed to evaluate for potential catheterization or other interventions.
Transport: Prepare for potential transfer to a higher level of care if indicated.
Contact Information:
Cardiology Team: Dr. Laura Mitchell, [Your Company Email]
Emergency Room: [Your Company Address], Room 105
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