Nursing Handover SBAR Template

Date / Time:

• 24/10/2023 - 14:30

Situation

• Patient John Smith, 68M, transferred from ED to Ward 4B with acute exacerbation of COPD and Type 2 Respiratory Failure. Requires ongoing nebuliser therapy and hourly monitoring.

Background

• Admitting diagnosis: Acute exacerbation of COPD
• Relevant medical history: COPD (diagnosed 2015), Hypertension, Type 2 Diabetes Mellitus

Assessment

• Current vitals: Temp 37.1 °C, HR 105 bpm, BP 138/85 mmHg, RR 26 breaths/min, SpO2 88% on 2L O2 via nasal cannula
• Recent clinical changes or events: Increased shortness of breath over the last 4 hours; responded moderately to initial salbutamol neb in ED.
• Pain score and management: 0/10 - No pain reported.
• Line/drain/wound status: 18G cannula in left forearm, patent, no signs of phlebitis or infiltration.

Recommendation

• Pending tasks or orders: Repeat ABG in 1 hour post-nebuliser; review by physiotherapist tomorrow morning.
• Follow-up monitoring required: Observation of respiratory rate and SpO2 every 30 minutes; notify medical team if RR > 28 or SpO2 < 88%.
• Scheduled medications or treatments: Salbutamol 5 mg nebuliser Q4H PRN; ipratropium bromide 500 mcg nebuliser QID; hydrocortisone 100 mg IV TID.