Question

Karen Cole, 56 year old female, Karen Cole, a school principal at White House High School. Admitted directly from the Dr.’s office to the IMCU after initial complaint for tightness in her chest, denies pain, and slight shortness of breath. Vital signs are BP: 168/92, P: 90, R: 24, T: 98.6. Her husband insisted that she come. She is insisting that she will only stay 12 hours, because she has to be back to school in the morning.

Write a SBAR report.

Answer 1

SBAR report.

The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition.

S	Situation Patient name: Ms. Karen Cole Age: 56 year old female Vital signs are: Blood pressure: 168/92, P: 90, R: 24, T: 98.6 Pulse: 90/mt Respiration: 24 b/mt Temperature: 98.6
B	Background The patient's mental status is: Alert and oriented to person place and time. She is completely normal. She is a school principal at White House High School
A	Assessment Initial complaints are tightness in her chest, denies pain, and slight shortness of breath. The problem may be related to cardiovascular or respiratory.
R	Recommendation Suggest or request that Transfer the patient to critical care. Talk to the patient or family about code status. Ask for a consultant to see the patient now. Tests The needed tests are CXR, ABG, EKG, CBC, or BMP ECG Treatment If a change in treatment is ordered then ask: How often do you want vital signs? How long to you expect this problem will last? If the patient does not get better when would you want us to call again?