SBAR-W10
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School
Seneca College *
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Course
101
Subject
Medicine
Date
Dec 6, 2023
Type
docx
Pages
1
Uploaded by AmbassadorLightningMoose10
SBAR report to physician about a critical situation
S
Situation
I am talking about
Mr.Sarazin.
The problem is about how the patient is alert but disoriented, can’t follow simple instructions, he has
developed a new onset of agitation and confusion over the past 48 hours and hasn’t been eating or drinking
for the past few days.
I have just assessed the patient personally:
Vital signs are
:
Blood pressure 81/40 Pulse 102 Respiration: 24 and temperature: 38.3 oxygen saturation:
92% on room air.
I am concerned about the:
How the vital signs are changing and how the patient is less responsive.
B
Background
The patient's mental status is:
Alert but disoriented, cannot follow simple instructions, confused speech with agitated behaviour
Patient’s health history: BPH, HTN,
osteoarthritis.
The patient
is not
on
oxygen. He
has a foley catheter in place.
.
A
Assessment
I think he might have an infection.
His vitals are changing, and the patient is less
responsive. I completed a head to toe assessment, these are my findings:
-alert but disoriented
-GCS scale of 13
-moving all 4 extremities spontaneously but doesn’t follow simple instructions
o
confused speech with agitated behaviour
o
air entry equal bilaterally but decreased to bases
o
abdomen is soft, tender by touch on lower quads bilaterally
o
loss of appetite for past 3 days (haven’t been eating)
-dark amber cloudy urine with visible pus
R
Recommendation
I
suggest that we do a blood culture to see if there is any infections
present
Tests needed:
CBC, blood work, urine culture, and blood culture, urinalysis, blood/serum electrolytes
This SBAR tool was developed by Kaiser Permanente.
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