Need a SBAR note
Situation:
Background:
Assessment:
Recommended:
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.
SBAR note :-
Situation: The patient came to the hospital with complaints of bloody vomiting and per rectal bleeding and is admitted for abdominal pain management
Background: The patient has been recently diagnosed with esophagus cancer. she feels a lot of pressure in her belly, throat, and chest.
Assessment: On assessment , his vitals are BP: 89/63, HR:89, O2: 89
Recommendations : -
1. Monitor the patient.
2. provide O2 if saturation is low
3. IV establishment
4.
5. Keep the patient warm.
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