SBAR Template week 3 PDF

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Download SBAR Template week 3 PDF

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SBAR Template Situation: Name/age: Marylin Smith 28 year old female

BRIEF summary of primary problem: 28-year-old female presented to the hospital on a voluntary admission as a result of suicidal thoughts after feeling “crummy” for the past six months. Patient complains of inability to sleep as well as a lack of energy to do things throughout the day. Patient also claims they cannot concentrate at work which is leading to taking sick time. Patient reports uncontrollable crying and feelings of uselessness as well as hopelessness and stated, “I don’t want to live like this anymore. I feel like I will never be happy again.” Pt was deployed in Iraq in non-combat and found her old boyfriend has married. She states she uses alcohol to fall asleep, but has no symptoms or signs of alcohol withdraw. Mentioned her grandmother at time being “withdrawn”, may be genetic factor

Day of admission/post-op #:

Background: Primary problem/diagnosis: Major Depresive Disorder, New onset

RELEVANT past medical history: Possible family history, Felt groggy the past 6 months, no other history

RELEVANT background data: Ex-military, saw no combat, past feelings of guilt and well as feeling overwhelmed when trying to complete routine tasks, having trouble staying concentrated at work, and crying more than usual.

Assessment:

Current vital signs: T: 98.8° F/37.1 (oral), P: 72 (regular), R: 12 (regular), BP: 92/66, O2 sat: 99% room air

RELEVANT body system nursing assessment data: Patient appears anxious

RELEVANT lab values: All lab values wnls currently

TREND of any abnormal clinical data (stable-increasing/decreasing): Currently stable and wnls How have you advanced the plan of care? Patient has been placed on Sertraline, Trazodone, and Lorazepam. Monitor patient on appropriate floor

Patient response: Not enough info given to evaluate.

INTERPRETATION of current clinical status (stable/unstable/worsening): stable

Recommendation: Suggestions to advance plan of care:

Monitor patients response to medication on appropriate unit. Contact md if any change in status progresses

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