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The resident is experiencing concerning vital sign changes and symptoms. Their blood pressure is over 200 or under 100, pulse is over 130 or under 40, and respiration is under 8 or over 30. The resident seems unstable and their condition may deteriorate further. The nurse is requesting orders from the physician, including possible tests like a CXR, ABG, EKG, or CBC. They want to know how frequently to take vital signs and when to call back if the resident does not improve with any treatment changes.

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205 views1 page

Sbar

The resident is experiencing concerning vital sign changes and symptoms. Their blood pressure is over 200 or under 100, pulse is over 130 or under 40, and respiration is under 8 or over 30. The resident seems unstable and their condition may deteriorate further. The nurse is requesting orders from the physician, including possible tests like a CXR, ABG, EKG, or CBC. They want to know how frequently to take vital signs and when to call back if the resident does not improve with any treatment changes.

Uploaded by

ayu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SITUATION

I am calling about
The resident’s Code status is:
The problem I am calling about is:
(e.g. I AM CONCERNED THE RESIDENT IS GOING INTO ARREST)

S
I have just assessed the resident:
Vital signs are: Blood Pressure / , Pulse ,
Respiration , and temperature

I am concerned about the:


Blood pressure because it is over 200 or less than 100 or 30 mmHg
below usual
Pulse because it is over 130 or less than 40 and symptomatic
Respiration because it is less than 8 or over 30
Temperature because it is less than 96 or over 104
Urine output because it is less than 25ml/hr or 200ml/8hrs
O2 saturation because it is less than 88% on 6/liters nasal cannula
Other:
BACKGROUND
The resident’s mental status is:
Alert and oriented to person, place, and time
Confused and cooperative or non-cooperative
Agitated or combative
Lethargic but conversant and able to swallow
Stuporous and not talking clearly and possibly not able to swallow

B
Comatose Eyes closed Not responding to stimulation.
The skin is:
Warm and dry
Pale
Mottled
Diaphoretic
Extremities are cold
Extremities are warm
The resident is not or is on oxygen.
The resident has been on (l/min) or (%) oxygen for minutes
(hours)
The oximeter is reading %
The oximeter does not detect a good pulse and is giving erratic readings.

A
ASSESSMENT
This is what I think the problem is:
“SAY WHAT YOU THINK IS THE PROBLEM”
The problem seems to be cardiac infection neurologic
respiratory
I am not sure what the problem is but the resident is deteriorating.
The resident seems to be unstable and may get worse, we need to do something.
RECOMMENDATION
From Physician
___________________

R
Transfer the resident to Emergency Room
Come to see the resident at this time
Talk to the resident or family about Code status.
Are any tests needed:
Do you need any tests like CXR ABG EKG CBC BMP
Others:
If a change in treatment is ordered then ask:
How often do you want vital signs?
How long do you expect this problem will last?
If the resident does not get better when would you want us to call again?

SBAR COMMUNICATION TO PHYSICIAN/PROVIDER

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