SBAR
S: We have Gabriel Martinez, 8 year old male, brought to the E.R for experiencing symptoms of asthma
exacerbations 4 hours ago.
B: Gabriel Martinez. DOB 2/4/15, Mom brought Gabriel in for s/s of respiratory distress, NKA, He’s
taking Albuterol 90 mcg 2 puffs. No med hx, just asthma.
A: Pre intervention vitals T: 37.2c, B/P 124/82, HR: 112 bpm, RR: 28, O2 94% RA, pain 4/10. Post
intervention vitals: T: 37.2c, B/P 124/82, HR: 122 BPM, RR: 20, O2 Sat 98% RA, Pain 4/10. Gabriel’s was
experiencing tachycardia, tachypnea with expiratory & inspiratory wheezing upon initial assessment.
Upon treatment, Gabriel has no adventurous sounds noted with lung auscultation with ability to speak
full sentences with no signs of dyspnea.
R: Education Gabriel & Mom on proper use of rescue inhaler. Have mom create an asthma action plan at
school, and educate on common side effects of medication.