Case
NR 351 SBAR Documentation for Anna Sink Assessment & Recommendation (GRADED A)
- Course
- NR 351
- Institution
- Chamberlain College Of Nursing
NR 351 SBAR Documentation for Anna Sink Assessment & Recommendation (GRADED A)
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NR305 Week 6 Anna Sink iHuman VirtualPatient Encounter Worksheet
Name: Lindsey Childresss
1. Situation, Background, Assessment, Recommendations (SBAR) Documentation
Write a focused SBAR note summarizing Anna Sink’s assessment for calling report to
social services. Include appropriate information in each section. Include all key findings
in each section. Data should be well-organized and concise. Documentation should be
professional with correct spelling.
This is a focused assessment SBAR; your summary should include a brief review of
pertinent findings. Type the appropriate information in each section below to develop your
focused SBAR note for end-of-shift documentation.
S Situation Anna Sink a 32-year-old African American, female teacher who
came to the ER with complaints of chest tightness, palpitations,
Concise statement and shortness of breath. This episode started when she heard
of the purpose of the the weather forecast was changing- delaying Anna 2 days from
communication her travel. Came into the ER and was given 2mg of PO
Lorazepam which helped the patient's anxiety a little.
B Background Anna's symptoms have continued 1-2x a week for 6 months.
She is feeling distressed from prolonged symptoms and
Brief information persistent feelings of doom. She always feels like something
related to the clinical bad is going to happen to her and has been having trouble
background of the concentrating. Anna takes Tylenol and Advil for headaches, and
situation. it seems to work. The patient has been going to therapy for 3
months “off and on” but is not sure if it has been effective.
Client stated, “I just feel like something bad is going to happen.”
A Assessment A&Ox4
No Allergies noted
Brief analysis and Drug toxicology test –
consideration of Anxiety 6/10
options No medical/surgical history.
Vital signs:
Temp: 98.6
HR: 98, regular.
Respirations: 18, regular, nonlabored.
Blood Pressure: 126/79
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6.13.23
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