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SBAR Template Situation: Name/age: Jack

Hamilton

BRIEF summary of primary problem: He came into the ER for difficulty breathing that has progressed throughout the morning Day of admission/post-op #: 1/15/20

Background: Primary problem/diagnosis: Asthma RELEVANT past medical history: Athma

diagnosed at 8 years old, seasonal allergies (takes

a daily Clariten) RELEVANT background data: Jack is a 11-year-old male who lives at home with his parents and 7-year-old sister. He has seasonal allergies, and he’s had asthma since he was 8 years old. Both his parents work busy jobs, so they depend on him to take his required medications regularly.

Assessment: vital signs T-37.2 C P- 110 R- 28 BP- 116/80 O2 sat- 88% Room Air

Respirations regular, symmetrical chest rise, tachypneic, moderatesevere retractions throughout. His lung sounds are diminished in the bases with expiratory wheezes throughout and a prolonged expiratory phase plus an intermittent cough. Bowel sounds normal. No heart murmurs, tachycardic, pulses +2 to all

extremities, cap refill 3 seconds to all extremities, skin warm and pale Neurological: Alert and oriented. Speaking short sentences, Anxious, pupils PERRLA and 2cm when constricted

Current vital signs: vital signs T-37.2 C P- 110 R- 28 BP- 116/80 O2 sat- 88% Room Air

RELEVANT body system nursing assessment data: Assess respiratory status: lung sounds, RR, SpO2 Tripod position Wheezing Reteractions Deep respiration

RELEVANT lab values: sodium 137, potassium 4, carbon dioxide 45, calcium 2.3

TREND of any abnormal clinical data (stable-increasing/decreasing): pH high=acidosis CO2 high=respiratory (from air trapping with asthma) HCO3=normal

WBC mildly high from inflammation/anxiety

How have you advanced the plan of care? Check MD orders Reassure pt and mother

Patient response: none INTERPRETATION of current clinical status (stable/unstable/worsening): stable

Recommendation: Suggestions to advance plan of care:

Maintenance of airway patency.

© 2016 Keith Rischer/www.KeithRN.com...