SBAR Report - SBAR PDF

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Description

SBAR Report Hello, my name is Justin Fleshman and I work on the med surg unit.

S

Mrs. Jones was admitted for reoccurring UTIs.

Situation Mrs. Jones has had approx. 6 UTIs with in the last month. Patient states that she stops taking her medications when she starts feeling better. She is asking multiple questions about her diagnosis, treatment and why she keeps getting them. She is on Cipro 400mg IV q12. Last does was given at 0900 this morning. Her next dose is due at 2100. She is also on Tylenol 650mg Q4 PRN for fever and pain relief. Her last does was at 1600 for a fever of 100.3 F orally.

B Background

Her main issue is her reoccurring UTIs. Mrs. Jones vitals are as follow as of 1900: BP-138/79, HR-94, SPO2 – 95% on RA, Respirations – 22 BPM, Temp – 98.7F orally, Lung sounds are WNL bilaterally. Pt does not have a foley cath in place. She is a fall risk due to weakness from UTIs. Patient has been using the call light for assistants. Education has been given to her, which is in care plan.

A Assessment

Mrs. Jones may need some more explanation and demonstration on proper perineal care. Also reiterate the importance of medication completion and frequent bath room breaks.

R

Is there anything else you need from me before I leave the floor?

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