SBAR Hand off for Mike Kelly PDF

Title	SBAR Hand off for Mike Kelly
Author	Maleah Martin
Course	Intro to Nursing Concepts
Institution	Owens Community College
Pages	2
File Size	87.3 KB
File Type	PDF
Total Downloads	81
Total Views	144

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SBAR Hand-of

Situation: Summary of situation 51 year old Caucasian male with hypertension

Background: married, self-employed smokes 1 ppd for past 31 years, eats fast food 3-5 times per week and does not exercise Primary diagnosis: complaints of being easily fatigued and has had a headache for the past 3 days with no relief. Pertinent medical history: biological father has a history of hypertension and MI Assessment: Current vital signs: Temperature: 98.6 Pulse: 82 Respirations:16 Blood pressure:176/104 Oxygen saturation: 96% on room air Current assessment findings: bounding pulse with pain 8/10 Abnormal lab results: bl oodpr es s ur e220/ 118 pai nf eel sac hyandi s8/ 10andi ti sac ont i nuousheadac he bounding pulse glucose BUN creatinine BNP lipid panel protein glucose urinalysis- blood RBC WBC

Interpretation of current status: Hypertension Recommendations: Monitor BP Q5 minutes Perform a repeat ECG Test Hemoglobin A1c Address lipid panel results...