Question

a patient has a history of CHF. Vitals P 128, Resp 30 per minute. BP 188/102. LOC, lung sounds crackl/ rales bilaterally, skin pale, cool and clammy.
please Fill out an SBAR using this scenario. thanks.

Answer 1

Question

a patient has a history of CHF. Vitals P 128, Resp 30 per minute. BP 188/102. LOC, lung sounds crackl/ rales bilaterally, skin pale, cool and clammy.
please Fill out an SBAR using this scenario. thanks.

Given explanation shows that patient is under shock or CHF again

Situation	Dr:x , i am ABC from emergency calling for ,Mr:x is admitted with hypertension,tachycardia and loss of consciousness.skin is pale cool and clammy
Background	Mr:x Has history of CHF ,vital signs are heart rate 128 bt/mint ,respiration 30br/mint and BP 188/102 today morning..Rales present in both lungs,skin is pale cool and clammy He does not have any allergies, lab results: scan results:ECG shows cardiac dysrhythmias Current medications:
Assessment	i think this is his Congestive heart failure again,that cause fluid retention in the body . and the situation is very emergency
Recommendation	i think we need to intubate and keep him in ventilator immediately i would like to get an ECG and CHEST X RAY stat.i will arrange for vasodiators.shall i start iv RL for him?should i arrange nitric oxide for him? i need you to evaluate him right away.we will be continuously monitoring his ECG.