Please write SBAR note with the following information. Thank you.
Question Answered step-by-step Please write SBAR note with the following information. Thank you.Molly Sawyer is a 66 year old female admitted from the Emergency Room with a diagnosis of Exacerbation of CHF. Her chief complaint is shortness of breath for 1 week which seems to have gotten worse today. Ms. Sawyer complains of persistent cough especially at night. She has had a weight gain of 20 lbs. Doesn’t smoke or drink alcohol. Eats a lot of canned foods. States her favorite activity is taking her grandchildren to McDonalds for a cheeseburger and fries. She does not regularly exercise. Medications: Clonidine 0.2mg po daily, Digoxin 0.25mg po daily, Insulin 70/30 35 units SQ in the AM History: DM, HTN, CAD After she has been settled in her room you come in to do your admission assessment. At that point you find the following assessment data: VS and other data per chart below, Moist rales right middle lobe and bilateral lower lobes, nail beds dusky, sitting upright leaning over the bedside table, difficulty talking, skin cool and moist, bilateral 2+ ankle and pedal edema. VS Labs CXR BP 218/110 Na 135 Bilateral pulmonary congestion HR 120 K 3.9 RR 36 H & H 12.5 & 33% T 97.1 Digoxin 0.6 12 lead ECG Creat. 1.9 Sinus tach w/ occ PVCs ABGs BUN 25 Old anterior MI pH 7.48 Serum BNP 252 paCO2 30 Total cholesterol 225 paO2 80 LDL 165 Ejection fraction Bicarb 24 HDL 45 30% SaO2 95% Triglycerides 250 Fasting glucose 221 HgA1C 6.8 S=SituationDescribe what is happening at the time to require the communication. B= BackgroundExplain any relevant background information that relates to the situation. A=AssessmentProvide an analysis of the problem or patient need based on assessment data. R=RecommendationState what is needed or what the desired outcome is. Health Science Science Nursing NUR 110 Share QuestionEmailCopy link Comments (0)
