SBAR
Vital signs, most recent labs, current patient condition
Background
Healthy skin that has no breaks, scrapes, cuts, or abnormal openings
Intact
Patient's oxygen saturation is 88% on room air
Oxygen
Breath sounds from a patient with asthma
Wheezes
Patient is incontinent
Impaired urinary elimination
What you want and think is appropriate to be done/ordered for the patient.
Recommendation
Upon palpating the patient's abdomen, there are no masses or firm areas noted.
Soft
Patient has been diagnosed with a bacterial infection
Antibiotics
A reduction in the loudness, tone, or regularity of sounds in the abdomen that indicate intestinal activity has slowed.
Hypoactive bowel sounds
Ineffective airway clearance
What patient you are calling about, brief statement about the current problem
Situation
You auscultate a "lub dub" sound when listening to your patient's heart.
Regular rhythm
The patient has urinary retention despite interventions to help him void and his bladder is measuring full
The patient is fully awake but is only aware of his name and where he currently is.
Alert and oriented x 2
Patient's oxygen saturation is low
Impaired gas exchange
What you think is going on with the patient
Assessment
Patient is fully awake and accurately states "My name is Barbara and I am at the hospital because I fell at home on Tuesday"
Alert and oriented x 4
The patient has been unable to swallow and choked during breakfast
NPO/swallow eval
The patient has swelling in both her legs and when the nurse presses them, an indent is left in her skin.
Pitting edema
Patient has a deep wound
Risk for infection/impaired skin integrity
The patient's admitting diagnosis and when he got admitted.
Background
The patient denies pain when you are palpating her abdomen
The patient is suspected to have anemia
CBC
Upon assessment, the patient's abdomen appears bloated and swollen.
Distended abdomen/abdominal distension
Patient is confused and weak
Risk for falls/injury