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    SBAR Report To Physician About A Critical Sitution

    Uploaded by

    Randolph Djanie
    The nurse is calling the physician about a deteriorating patient. Vital signs show blood pressure over 200 or less than 100, respiration less than 5 or over 40, and temperature below 96 or over 104. The patient is lethargic but able to swallow. Skin is pale and extremities are cold. The nurse assesses the problem as possibly cardiac or infection related and feels the patient is unstable and may worsen. The nurse recommends transferring the patient to critical care or having the physician come see the patient now.

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    SBAR Report To Physician About A Critical Sitution

    Uploaded by

    Randolph Djanie
    316 views3 pages
    The nurse is calling the physician about a deteriorating patient. Vital signs show blood pressure over 200 or less than 100, respiration less than 5 or over 40, and temperature below 96 or over 104. The patient is lethargic but able to swallow. Skin is pale and extremities are cold. The nurse assesses the problem as possibly cardiac or infection related and feels the patient is unstable and may worsen. The nurse recommends transferring the patient to critical care or having the physician come see the patient now.

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    SBAR report to physician about a critical sitution

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    The nurse is calling the physician about a deteriorating patient. Vital signs show blood pressure over 200 or less than 100, respiration less than 5 or over 40, and temperature below 96 or over 104. The patient is lethargic but able to swallow. Skin is pale and extremities are cold. The nurse assesses the problem as possibly cardiac or infection related and feels the patient is unstable and may worsen. The nurse recommends transferring the patient to critical care or having the physician come see the patient now.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    316 views3 pages

    SBAR Report To Physician About A Critical Sitution

    Uploaded by

    Randolph Djanie
    The nurse is calling the physician about a deteriorating patient. Vital signs show blood pressure over 200 or less than 100, respiration less than 5 or over 40, and temperature below 96 or over 104. The patient is lethargic but able to swallow. Skin is pale and extremities are cold. The nurse assesses the problem as possibly cardiac or infection related and feels the patient is unstable and may worsen. The nurse recommends transferring the patient to critical care or having the physician come see the patient now.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    SBAR report to physician about a critical sitution

    Situation
    I am calling about <patient name and location>

    s
    The patient’s code status is <code status>
    The problem I am calling about is_______________________________.
    I am afraid the patient is going to arrest.

    I have just assessed the patient personally:

    Vital sign are: Blood pressure _____/___Plus _____Respiration _______and temperature ______

    I am concerned about the:


    Blood pressure because it is over 200 or less than 100 or 30 mmHg below as usual
    Plus because it is over 140 or less than 50
    Respiration because it is less than 5 or over 40
    Temperature because it is less than 96 or over 104

    Background
    The patient’s mental status is:

    B
    Alert and oriented to the person place and time.
    Confused and cooperative or non-cooperative
    Agitated or combative
    Lethargic but conversant and able to swallow
    Stuporous and not talking clearly and possibly not able to swallow
    Comatone, Eye closed, Not responding to stimulation.
    The skin is:
    Warm and dry
    Pale
    Mottled
    Diaphoretic
    Extremities and cold
    Extremities and warm
    The patient is not or is on oxygen:
    The patient has been on ______ (1/min) or (%) oxygen for ________ minutes(hours)
    The oximeter is reading __________%
    The oximeter does not detect a good pulse and is giving erratic readings.

    Assessment

    A
    This is what I think the problem is : <say what you think is the problem>
    The problem seems to be cardiac, infection, neurologic, respiratory _____________.
    I am not sure what the problem is but the patient is deteriorating.
    The patient seems to be unstable and may get worse, we need to do something.
    Recommendation

    R
    I suggest or request that you <say what you would like to see done>
    Transfer the patient to a critical care
    Come to see the patient at this time.
    Talk to the patient or family about code status.
    Ask the on-call family practice resident to see the patient now.
    Ask a consultant to see the patient now.
    Are any test needed:
    Do you need any test like CXR, ABG, EKG, CBC, or BMP?
    Others?
    If a change in treatment is ordered then ask:
    How often do you want vital signs?
    How long do you expect this problem to last?
    If the patient does not get better when would you want us to call again?
    SOAP DOCUMENTATION

    SOAP documentation is a problem-oriented technique whereby the nurse identifies and list the
    patient’s health concerns. It is commonly used in primary health-care settings.

    Documentation is generally organized according to the following headings:


    S= Subjective data

    Example: what is the patient experiencing or feeling, how long has this been an issue, what is the
    frequency, intensity, duration, what makes it worse or better, any past history, family history hence
    monitoring result ( BP, weight, glucose monitoring)

    O= Objective data

    Example: Result of the physical exam, relevant vital signs, what the nurse observed etc.

    A= Assessment

    Example: What is the nursing diagnosis or medical diagnosis (for existing problem), identification of
    the problem, etc.

    P= Plan

    Example: What interventions are done during the visit, what is the follow up, what medications have
    been prescribed or changed, what further testing or investigation are required, when will the patient
    be seen again, etc.

    Sample Chart Note:

    S: In for refills and review of diabetes. Home glucose monitoring, taking BG readings 3 times/weeks
    in the morning only (fasting). Average BG 7-8. Has been trying to avoid sugary snacks.

    But has just quit smoking so finding this is difficult. Walking 5 times/week for 30 minutes.

    O: Blood work- A1C 7.2 (was 7.3), LDL 1.9, Ratio 3. BP 118/70, HR 72 regular.

    A: Diabetes (A1C not a target).

    P: Provided with information on A1C, diabetes and targets. Provided with support.

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