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junior1999

SBAR TEMPLATE

S
SITUATION
Name: Mr. Jones 46 years old black male , uncontrolled high blood pressure and occasional tachycardia.

B
BACKGROUND
Patient is a smoker with 20 years of smoking 1 pack of cigarette per day . Diagnosed with heart murmur at age 12. High blood pressure in 2013. Myocardial Infarction on 4/13/2014. Patient was admitted at Columbia Hospital, and received cardiac stent placement on 4/14/2014. Patient on multiple cardiac medications and follow up with cardiologist every 3 months for stress test.
Medications
Metoprolol Titrate 50 mg tablet twice a day.
Clonidine .2 mg three time a day
Coreg 25 mg twice a day
Lisonopril 10 mg daily
Zocor 80 mg daily

A
ASSESSMENT:
Vital signs: Blood pressure 178/94, Pulse 101, Temperature 98, respiration 18, patient is not on oxygen .
Weight : 185 pounds Height 5’6”
Marital status: Married with 2 children
Occupation: Truck driver, working under stress
Smoker: yes 1 pack per day
Drinker: No
Diet: Consists of three meal a day snacks in between likes meat products , fried chicken , eats vegetables and fruits occasionally.
Activity: none
Family History: father died with lungs cancer, mother has high blood pressure.
NURSING DIAGNOSIS: At risk for decrease cardiac output , and risk for heart failure. R
RECOMMANDATION:
Monitor vital signs every 4 hours
Physical assessment including daily weight , monitor intake and output every 8 hours
Life style changes including weight and stress management
Mr. Jones is 46 years old black male , in 2013 during routine physical examination, his primary care physician referred him to cardiologist for further evaluation. Patient was diagnosed with high blood pressure and started on lisinopril

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