Question

Need a SBAR note.

DX: The patient admitted for abdominal pain.

Patient's symptoms: blood vomiting and blood discharge from the rectum.

Vital Signs: BP: 89/63, HR:89, O2: 89

History: The patient has been recently diagnosed with esophagus cancer. she feels a lot of pressure in her belly, throat, and chest.

Healthcare provider's orders: 1. Provide Normal Saline bolus of 500mg.

2. Monitor the patient.

3. provide O2 if saturation is low

   4. IV establishment

   5. Keep the patient warm.

nursing action: 1. O2: nasal cannula 6L,

   2. IV: maximum

   3. assess fast then notify the doctor.

Answer 1

S	Patient admitted for abdominal pain and is complaining of blood vomiting, blood discharge from the rectum.
B	Patient has been recently diagnosed with esophagus cancer, She feels a lot of pressure in her belly, thorat, and chest
A	Current observations are: Blood pressure: 89/63, Heart rate : 89, Spo2 : 89%
R	I recommended that : Provide Normal Saline bolus of 500mg. Monitor the patient. Provide O2 if saturation is low. Keep the patient warm. IV establishment. Nursing action: O2 ; nasal cannula 6L IV ; Maximum Assess fast, is there anything notify the doctor immediately.