SBAR for COPD and pneumonia PDF

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Summary

ATI Sims for COPD on the patient Gomez...

Description

SBAR SHIFT →SHIFT REPORT This form is to assist in performing complete, precise patient hand off from shift to shift. Situation Patient Name: Gomez, Hector

Age: 68 Sex: Male

Level of Care: Independent Physician: Peelze, Robert Admitted from: Home

Background Admission Diagnosis: pneumonia with acute exacerbation of COPD Date of Surgery (if applicable): N/A Pertinent past medical history: smoking, alcohol abuse, hyperglycemia, COPD

Assessment Code Status: N/A Abnormal V.S. BP 150/94, RR 36, HR 100, O2 91% IV site – lock/fluids/site/drips/when to change IV site: Saline lock in left wrist Procedures done in the last 24 hours (include any known results): _________________ Abnormal Assessments: diminished lung sounds at base, rhonchi, wheezing in both upper lobes posterior & anterior, greenish-yellow tenacious sputum, possible anorexic Current pain score: 0 What has been done to manage this plan: Safety needs/fall risk /skin risk, etc.: Fall risk, risk for respiratory failure

Recommendation Needed changes in the plan of care? (diet, activity, medication, consult): What are you concerned about? O2 stats, Discharge Planning: None currently Pending labs/x-rays, etc: ABG’s, Blood alcohol, CBC, chest X-ray, chem and metabolic profile, urine analysis/culture, sensitivity of sputum Call out to Dr. ______________________ about _______________________________ What the next shift needs to be aware of: Monitor his O2 and VS, his a fall risk 1/2009 sg #NUR182

*Document any change in condition and physician notification on patient MR...