Free SBAR for Nurses

I. Situation

Date: August 27, 2050
Location: [Your Company Address]
Patient Name: Jane Doe
Patient ID: 123456
Nurse on Duty: [Your Name]

II. Background

Jane Doe, a 54-year-old female, was admitted to our facility on August 26, 2050, with symptoms of acute respiratory distress and a history of chronic obstructive pulmonary disease (COPD). She has been receiving oxygen therapy and nebulized medications. Her medical history also includes hypertension and type 2 diabetes.

Recent Vital Signs:

III. Assessment

The patient’s respiratory distress has improved slightly with current treatment. However, her oxygen saturation levels are fluctuating between 88-92%, which is below the desired range. Jane appears to be increasingly anxious and is experiencing occasional bouts of confusion. There are no signs of immediate distress or new acute symptoms.

IV. Recommendation

1. Immediate Actions:

   • Increase the oxygen flow rate and monitor saturation closely.

   • Administer a calming medication as per the physician’s protocol to manage anxiety and confusion.

2. Further Monitoring:

   • Continue to assess vital signs every 2 hours and document any changes.

   • Re-evaluate the need for additional respiratory therapies or interventions based on patient response.

3. Consultation:

   • Request a consultation with the pulmonologist for a possible adjustment to the treatment plan.

   • Schedule a meeting with the patient’s primary care physician for a comprehensive review.

Prepared by: [Your Name]

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