Healthcare SBAR
I. Situation
Patient:
Erica Price
Date of Admission:
August 25, 2050
Diagnosis:
Chronic Obstructive Pulmonary Disease (COPD)
Current Status:
Erica Price has been stable but requires continuous oxygen therapy and regular medication adjustments. She has recently been experiencing increased shortness of breath and a slight fever.
II. Background
Medical History:
Condition | Details |
|---|
COPD | Diagnosed in 2020, managed with inhalers and steroids |
Hypertension | Managed with medication |
Diabetes Mellitus | Type 2, controlled with oral medication |
Recent Treatments:
Oxygen Therapy: Administered via nasal cannula, 2 liters per minute
Medication: Inhaled corticosteroids and bronchodilators; recent dose adjustment due to worsening symptoms
Recent Lab Results:
III. Assessment
Erica Price's condition is stable but requires monitoring and potential adjustment of her treatment plan. She has exhibited increased respiratory distress and fever, which may indicate an exacerbation of COPD or an infection. Immediate attention is needed to evaluate these symptoms and adjust her care plan accordingly.
IV. Recommendation
Immediate Actions:
Increase oxygen flow rate to 3 liters per minute.
Administer a dose of antibiotic as per the protocol to address possible infection.
Arrange for a follow-up chest X-ray and blood work in 24 hours.
Follow-Up:
Monitor Jane’s response to the increased oxygen and medication adjustments.
Review lab results once available and adjust the treatment plan as necessary.
Ensure that Erica receives education on recognizing signs of worsening symptoms.
Contact Information:
Primary Physician: Dr. Antonette Cassin, antonette@you.mail
Nurse in Charge: [Your Name], [Your Email]
Prepared by: [Your Name]
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