_ NAME. \Yaden Tele SBAR~ TOOL for CRITICAL THINKING 3743. PROFESSIONAL NURSING 3 S (Situation) RECENT Clinical Data: Pt initials Age ee Rm#_4507A — Admission date_02/04/?022. Diagnosis Sep6:S, UTS Durkee cena Caller leet Longoria, teayeardin Secondary Diagnosis Altered ment: Shekus , Weebreds iG Surgery/Procedures & Date_ pA fe yl Activity 68 Solerehe) _ Consuits_ gt oy, ntpreslag Oure, i Maio diseete, Pr Code Status & Pertinent Data Collection NN tle Vives nk rw wl dhe hte Oe pag hapielieg dion Lae midtte\ Wwithery its prwey Pk ShiPod oy spoliere en ts se 40 Phy es Aas — Pathophysiology of Pertinent Diagnoses _S¢psi$ - inky Aen oF Ye ble. Yuet Con dered Ye nlite efferent —Sygdemt Gadde 6s wtabeess , Qethed munlal Gets md Wewkneg an tha pd. “v Results of Dx Tests/Blood Work/ Procedures ~ Include Significance of Results bun = S€ _cwrrrel 23 my idl SSympbew of cue onl Cibo Uctrtinine - 3.5 pote! 0.7-\dag ld OO - 14.) normal 4.S- WS sympkome ae er Wet = N44 24.9 pomel 1O$- 1G + 37 S49. p= __£ Ths cn pas wis Fc . + fin ke ea $ Wi8O Irafreatment and Times for Plan of Care: B (Background) Medical history Surgical history & Family history pertinent to current care diagnosis So mia Thy RR mecy . otensiully Seas phyim ab VP Nant Forly eek ty Rtn A (Assessment) Information on the latest findings that effet the most recent clinical status ofthe patient Vital Signs_ 91-1" ©, BE ben WA/ BE aEmne, 4 Recent Dx tests/labs Special equipmem 02 _GSsiBsite Safety Concems XL cise (wees « GVbered Mrentel Aelns) D/t Abnormal Assessment Data & Significance to Patient: lore Orhremhy Weekes cord by ae tel | Target Assessment & explain why Wun fet Muro 4S Ye hegeh asSestinvh pesessng VOC and ar itntllten 1 Ce We eeIV Therapy_Onbiboi ah $ Ivtypesite R+L Corer 20 List Meds as related to Current Diagnosis/Condition, Use Medication sheet for drug information. Prpercuiblin ~ kzebactom (2eS¥n) 337mg im OSt ~H¥ far Sepsis ond UtT Sedim iptac 650mg UY ee eae Por aerbe ctrch Riley List Meds related to Chronic Diagnosis/Condition. Use Medication sheet for drug information, ne ame pave Cangitens vy Analysis ofthe Problem/Patients Current Condition: gets nee ty ad Hee aes oP ont bites ho 7 a ee yeti, Vee wt Cote WS tee. eeaaheed } 4 R (Recommendations) Information for FUTURE Plan of Care: Future Assessment/Activities Monitoring O10 SIrnghth for pou's oJ written probly mm bed on an Sachsant/Pamily Concerns: Collaboration done with Cover Nurse/Other Disciplines and Pt Care issues discussed: i. ORK _4r ae = “A. \ Ah i> Identify THREE Problems & Collaborative Interventions for this Patient. ACTIVE PROBLEM INTERVENTIONS EVALUATION is will catia wl be Alkerd mute 7 pea Sess tady shh t Sokes So evtlngle Wl af Coreingners Ad cwwewereti of orton] Plow | Hee eS ee oS naa Sinpsscd enabll i € ae ie — er horefir alelty watt ge | SN Noe ah at Sy ej ord bike od tak! 66 pa de assess ie Gest nett ce, ond on kek enusdle — Shrngh Covdnetion ond Level Of aSSiSt rede) WM ber herbed ee 4 — cist for impaired Werte eatiety So a SEN asyesmuat erry wey Crom VIN Noe grefermal, | carey taka tty | WY Oe Ned bo skin ond SHU Yo tee on th sith ) GD Yur Sheba Wer hey Yo pete ef talnnn | 4