SBAR Template

Situation:
Name/age: SB
BRIEF summary of primary problem: he was causing disturbances in the
neighborhood. Patient was yelling out,

Day of admission/post-op #: 2/22/21

Background:
Primary problem/diagnosis: left sided heart failure diabetes

RELEVANT past medical history:Type II Diabetes Meliltus (Type II DM), and Hypertension (HTN).
transportation. Patient was prescribed with Zestril (lisinopril) 10 mg daily,
Glucophage(metformin) 500 mg twice daily with meal, Lantus (insulin glargine) 15
units at bed time, Haldol (haloperidol) 10 mg at bed time,
Cogentin (beztropine) 2 mg at bed time, Ativan (lorazepam) 1 mg as needed every 6
hours for anxiety and Eskalith (lithium
carbonate) 300 mg twice daily.
RELEVANT background data Patient is 45 years old male, unemployed and disabled. Grduated high
school, has some college education and has
no military service or history of incarceration. Patient is currently living with his ederly parents who
are in their 70s and does not
have any siblings. Patient denies use any illicit substance and denies EtOH use. However, patient has
history of substance abuse
and EtOH dependence.

Assessment:
Current vital signs:
vital signs
T128/86

P: 94

R: 24

T: 99.0
RELEVANT body system nursing assessment data: His appearance is disheveled, apparent body odor
noted, soiled
clothing, wearing multiple shirts and large coat despite it being 98
degrees outside.

RELEVANT lab values: None

TREND of any abnormal clinical data (stable-increasing/decreasing):

stable

How have you advanced the plan of care?

Consult tele-psych for initial mental health evaluation. Continue with

5150.2 monitor vitals
signs and pain scale

Patient response: none

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

Recommendation:
Suggestions to advance plan of care:
Continue observation and monitor V/S. Place patient on one to one observation

© 2016 Keith Rischer/www.KeithRN.com