Fill an hypothetical client SBAR report for a nurse in United States

Certainly! An SBAR report is a structured method of communication that stands for Situation, Background, Assessment, and Recommendation. Below is a hypothetical example of an SBAR report for a patient under a nurse's care in the United States. --- **SBAR Report** **S: Situation** - **Patient Name:** Jane Doe - **Age:** 67 - **Room Number:** 204 - **Date/Time:** 10/20/2023, 10:30 AM - **Pulse:** 118 bpm - **Blood Pressure:** 130/85 mmHg - **Temperature:** 99.5°F - **Oxygen Saturation:** 92% on room air - **Main Issue:** The patient is experiencing increased shortness of breath and mild confusion. She has a history of chronic obstructive pulmonary disease (COPD) and was admitted for pneumonia. --- **B: Background** - **Medical History:** Patient has a 10-year history of COPD, hypertension, and type 2 diabetes. She has been hospitalized for exacerbations of COPD in the past. - **Medications:** Currently on bronchodilators, corticosteroids, and oral hypoglycemics. - **Recent Progress:** Patient was stabilized upon admission but has shown a gradual decline in respiratory status over the last 12 hours, requiring increased frequency of albuterol nebulization. She is also requiring more assistance with activities of daily living. --- **A: Assessment** - **Respiratory:** Increased work of breathing noted; patient is using accessory muscles and exhibiting a prolonged expiratory phase. - **Neurological:** Mild confusion and disorientation have developed; she is alert but having difficulty recalling the day’s events. - **Hydration/Nutrition:** Patient has had reduced oral intake due to fatigue and nausea. IV fluids are being administered as per protocol. --- **R: Recommendation** - **Immediate Actions:** 1. Increase the frequency of nebulizer treatments to every 2 hours and consider escalating therapies to include systemic corticosteroids. 2. Monitor vitals closely and consider arterial blood gas (ABG) analysis to assess oxygenation and carbon dioxide levels. - **Additional Considerations:** 1. Consult the respiratory therapist for optimization of respiratory treatment. 2. Notify the physician of current status and any changes in the patient's condition. 3. Review and optimize nutritional support, possibly involving the dietary team. --- **Nurse’s Name:** Sarah Johnson, RN **Contact Number:** (555) 123-4567 --- This hypothetical SBAR report format helps convey critical information succinctly and clearly, ensuring effective communication between healthcare team members.