Using the SBAR format, identify the info. Nurse Allyson received from report that will enable her to
provide safe care to Mr. Jones. - Answer--S- Situation
The ED admitted Mr. Jones at 4:30 AM for SOB and weakness. After treatment, he is transferring to the
telemetry unit.
B - Background
60 year old African-American male with a history of peripheral vascular disease, type 2 diabetes, chronic
kidney disease, coronary artery disease, and atrial fibrillation. A provider recently discharged him from
the facility after he treated Mr. Jones for atrial fibrillation and a type 2 diabetic ulcer of the right foot.
Mr. Jones did not complete prescribed antibiotics after his discharge. He is non compliant in managing
his diabetes. He smokes one pack of cigarettes a day and uses alcohol 3 to 5 times a week.
A - Assessment
Mr. Jones is awake, alert, and orientated x3. Current vitals are: BP 112/70, P: 158, R: 34, T: 99.1, and O2
sat 91% on 2 L via nasal cannula. ECG indicates atrial fibrillation; placed on telemetry. Chest x-ray:
opacities greater in the right lung than left lung. Altered lab values include: sodium 128, potassium 5.1,
BUN 44, creatinine 3.0, and glomerular filtration rate 25. His total bilirubin was 2.8, calcium 8.7, WBCs
16.1, hemoglobin 9.3, hematocrit 28.2, and blood glucose 71. We did a digoxin level, which was 0.6. He
has a soiled dressing on his right foot and is a stage III ulcer. A #20 gauge IV catheter was inserted
peripherally in his left forearm and a nurse gave him 1,000 mL of 0.9% sodium chloride. Intake: 1,000 mL
Output: None. No family present.
Nurse Allyson is preparing to call the provider about Mr. Jones's difficulty breathing. Which of the
following orders should she recommend to the provider? - Answer--Furosemide (Lasix) 20 mg IV
Nurse Allyson is planning care for Mr. Jones, who has clinical manifestations of phlebitis. Which of the
following is the priority action the nurse should take? - Answer--Remove the IV catheter.