7 / SBAR - TOOL for CRITICAL THINKING 3743. PROFESSIONAL NURSING 3 Pt am ine bear Rmi 4397 Admission date Q1G)AQ Diagnosis non-STelevated tayscurdta@ tinferchsoa Secondary Diagnosis_ Aaa Abmillatioa HTN, brondaihs Surgery/Procedures & Date} acy Ady os lence Consults PTC) Pt Code Status & Pertinent Data Collection “s furs NAME, Aiome no |nstou of uhildmis EO visit. Pathophysiology of Pertinent Diagnoses Nun es Scanned with CamScannerTreatment and Times for Plan of Care: (lead EKG rn if pt expenence ovest pain or atorortnc heart Phe tt POCe Intermitent preumariccamression dévice—until Atccontinweel, Intace + antout- Qe, daity wets vite signs. per watt routine wail diecntaned Helerrctiny onto - asl B (Background) Medical history, Surgical history & Family history pertinent to current care/diagnosis. Medical bik: artettis . Surgicah histo: one one Favnty Wistiniokon fie A (Assessment) Information on the latest findings that effect the most recent clinical status of the patient. Vital Signs 94.5°F, P:5F Riad pO: Hay pul dy C4) Recent Dx tests/labs Petatsivam:3.AbL, prcalcttoin 0.107 high emcrubyraprin: Qt Special cquipment framt ylatel tir, Conhensns Nelenrns rannitariaey Sefexy Concer Hah Gays et Abnormal Assessment Data & Significance to Patient: The, ph has impaired hearig in both Cars. SHE also hac impaired viston and wears glasses. She algo fias hypertension on 3 dvfrent occassions . Target Assessment & explain why: My torget ascescrnunt for Anis gt. is cardiovasoalar sushern lecccunte she had on NSTEMI 8 das ayo. She has ateo been haar reamment episcder of atrial frbrillahon, ater H+ extrornely umporteag = 4oossas H2 anh Wugtna. She a dia to have bujpertensive cries wha weed, to chil yrunirton Scanned with CamScannerFr vherapy Normal cine eke av TypelSite_poriguaal [Vert ankcubital Ag List Meds as related to Current Diagnosis/Condition. Use Medication sheet for drug information. morapaldd tarrate | Loptescer) oma sl (ri) Pasuvattatan (crest) Yong prolteraperaine (compazine) Bing Otntedt pre, (Narvese) Lom Aspiin Blea, List Meds related to Chronic Diagnosis/Condition. Use Medication sheet for drug information. level xine ( Syntrwid ) 50m Iageeretvnagidd-trayntrte (wav 2id,) 37-5 -A5rq Arsen (dittworn) asteny ‘Analysis ofthe Problem/Patients Current Condition: . pegnted ED with Fag and CyalL O-RD, Subseueriny dig. with NCTEML ard byperreree, emergent Currentiy pe TS Skt wanting Ioypartenswe cries emerqomey ugen vital sign assessment. R (Recommendations) Information for FUTURE Plan of Care: Future Assessment/Activities/Monitoring iat kare Sil ins uy dang activi fe. Teaching/Discharge Planning!"The. feain inkawention +n tena this gh Ls fo not overdo Scanned with CamScannerPatient/Family Concerns: Ther doutr wd utc. Collaboration done with Cover Nurse/Other Disciplines and Pt Care issues discussed: Throughout 41 shiFt, | colldonated wit rod wise negordnay tue react recon BP readings, Valse worked wan PT alt begin ce ve ShiPk hetplag nay pt corel ceHe eu erencices. Identify THREE Problems & Collaborative Interventions for this Patient. ACTIVE PROBLEM INTERVENTIONS EVALUATION Activity Intolerance Inston ot The en meh Nes a eed drs. ae ie aerelee Vie 0 gupply ard det Or weal oturcises an oo bce ol as Readiness for Enhanced ciliata wit Tet eae amd fermnily 40 i as wediscusceel Health manawgernent cf Steeges 1 0 rage nie new Ons hy pertonstan ‘ae Hatha pr is discharged. Decreased cuidiac output Oh Be Tas ord geal Teeter med, as win heart rate Condition bebe da rin Tisten | ass her vitals beAre wile indication ncpt), alse her nidiarall Scanned with CamScanner