Viola Cumble, 92yr-old, second day post-op hip repair, Allergic to Penicillin. Vital sign Temp 98.4, BP 136/78, P 72, RR 20, SaO2 97%. Normal Sinus Rhythm on telemetry. Alert and cooperative. No weight bearing today. Skin warm and dry, may sit up on edge of bed today. Needs frequent reminding due to determination to do things herself without assistance. Wound clean dry and intact. Regular diet. Dr. Starks
Write a SBAR report.
SBAR means
S -Situaatiin.
B- Background
A-Assessment
R-Recommendation
S- Viola Cumble ,92 years old who has admitted for Hip repair and now on second post op day.
B- Viola Cumble is known allergic to penicillin. She is alert and conscious and very much cooperative to health care workers and her procedures. Now she is able to sit on bed by side.
A- Vital signs are normal,afebrile ,hemodynamically stable.Her cardiac function status remains normal as evidenced by normal rhytham. Surgical wound remains intact and free of infection .She is on normal diet.
R-Encorage her to do activities with out assistance for enhancing progress .
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