SBAR
S
SITUATION
NAME: Robert DeBourgAGE: 62
GENDER: Male
Patient’s main concern is Uncontrolled Blood Pressure and occasional Tachycardia.
B BACKGROUND
Patient is a smoker with 20 years of smoking ½ pack of cigarette per day.
Diagnosed with Heart Murmur at age 12.
Diagnosed with High Blood Pressure in 2013. Mayocardial Infarction on 4/13/2014, Patient was admitted at St. Rose Hospital and received Cardiac stent placement on 4/14/2014. Patient is on multiple cardiac medication and following up with cardiologist every 3 months for stress test.
A ASSESSMENT
VITAL SIGNS:
BP:163/82 PULSE: 76 TEMP:98.2 RESPIRATION:16
PATIENT IS NOT ON OXYGEN
WEIGHT: 223, HEIGHT: 5’9
MARITAL STATUS: Married with 3 adult children.
OCCUPATION: Air traffic controller, working under stress
SMOKER: Yes, ½ pack of cigarette per day
DRINKER: No
DIET: Consists of meat products, sugar, occasionally add vegetables and fruit
ACTIVITY: None
FAMILY HISTORY: None
NURSING DIAGNOSIS: At risk for decreased cardiac output and at risk for heart failure.
R RECOMMRNDATION
Daily Vital Signs monitoring
Physical assessments including fluid balance, skin and weight
Life style changes including weight and stress management
Mr. Debourg is 62 year old male. In 2013, during routine physical with his physician, he was referred to a cardiologist for further evaluation. Patient was diagnosed with high blood pressure and started on Lisinopril 10mg daily. Due to stress from work, he started having palpitation and shortness of breath. On 4/13/2014, patient started feeling hot and dizzy. When his wife noticed patient’s face was turning pale, she took his blood pressure. Patient states he’s blood pressure at that time was around 200/100, heart rate above 150. Mr. DeBourg drove himself to the hospital where he was admitted for further evaluation and tests. Angiogram showed 2 blocked arteries and he received Cardiac stent placement. Patient is now on 4 blood pressure medications and sees cardiologist
SITUATION
NAME: Robert DeBourgAGE: 62
GENDER: Male
Patient’s main concern is Uncontrolled Blood Pressure and occasional Tachycardia.
B BACKGROUND
Patient is a smoker with 20 years of smoking ½ pack of cigarette per day.
Diagnosed with Heart Murmur at age 12.
Diagnosed with High Blood Pressure in 2013. Mayocardial Infarction on 4/13/2014, Patient was admitted at St. Rose Hospital and received Cardiac stent placement on 4/14/2014. Patient is on multiple cardiac medication and following up with cardiologist every 3 months for stress test.
A ASSESSMENT
VITAL SIGNS:
BP:163/82 PULSE: 76 TEMP:98.2 RESPIRATION:16
PATIENT IS NOT ON OXYGEN
WEIGHT: 223, HEIGHT: 5’9
MARITAL STATUS: Married with 3 adult children.
OCCUPATION: Air traffic controller, working under stress
SMOKER: Yes, ½ pack of cigarette per day
DRINKER: No
DIET: Consists of meat products, sugar, occasionally add vegetables and fruit
ACTIVITY: None
FAMILY HISTORY: None
NURSING DIAGNOSIS: At risk for decreased cardiac output and at risk for heart failure.
R RECOMMRNDATION
Daily Vital Signs monitoring
Physical assessments including fluid balance, skin and weight
Life style changes including weight and stress management
Mr. Debourg is 62 year old male. In 2013, during routine physical with his physician, he was referred to a cardiologist for further evaluation. Patient was diagnosed with high blood pressure and started on Lisinopril 10mg daily. Due to stress from work, he started having palpitation and shortness of breath. On 4/13/2014, patient started feeling hot and dizzy. When his wife noticed patient’s face was turning pale, she took his blood pressure. Patient states he’s blood pressure at that time was around 200/100, heart rate above 150. Mr. DeBourg drove himself to the hospital where he was admitted for further evaluation and tests. Angiogram showed 2 blocked arteries and he received Cardiac stent placement. Patient is now on 4 blood pressure medications and sees cardiologist