What information should the nurse include when using the SBAR technique ATI?
Example #3: Night Nurse Giving SBAR Report to Oncoming Nurse for Patient Admitted During the Overnight Shift• Situation:“Mrs. Thomas, in room 316, is an 84-year-old female admitted last night at 2230. She arrived at the emergency rule via ambulance from Magnolia Nursing Home where she reportedly fell trying to go to the restroom unattended.”• Background:“Mrs. Thomas has a history of Alzheimer's and diabetes. She is a no-code patient, and supporting documentation has been scanned into her chart. Her next of kin was notified by the nursing home about her fall, and I phoned the son to report her admission to our facility. Her son states that he and his sister will be arriving this morning to be with her and meet the doctors.”• Assessment:“Radiology report indicates intertrochanteric hip fracture. Although her right thigh and hip are bruised, her skin is intact. Vital signs remain stable. She denies pain presently. Her last pain medication was morphine at 2300 while in the ER. She has denied the need for any pain relievers since that time.”• Recommendation:“Surgeon has been consulted but has not yet confirmed surgery for this morning. I recommend continued pain assessment and follow-up with surgery to determine plan of action.”Example #4: Patient at Physician’s Office Being Made a Direct Admit to Hospital• Situation:“This is Christy Rials, RN, from Dr. Burgess' office calling to give report on a patient Dr. Burgess is sending as a direct admit. The client, Ms. Chasity Lewis, arrived at the clinic this morning and, based on her chief complaint of weight loss, a blood sugar assessment and urinalysis were performed. Based on the result, Dr. Burgess diagnosed Ms. Lewis with Diabetes.”• Background:“Ms. Lewis reports a 21 lb. weight loss in less than a month, which is consistent with her health records. Today's weight in the clinic is 131 lbs. She weighed 152 at her last visit here four weeks ago. She also reported frequent hunger, thirst, and urination. The patient has no significant health history, no food or drug allergies, and no complaints of pain or other concerns.”• Assessment:“Urinalysis revealed the presence of ketones in the urine, and her blood sugar was 432 mg/dL.”• Recommendation:“Medication orders attached to admission order in the EHR. Additionally, the patient requires monitoring of blood sugars before meals and at hs. Request nutritionist consult to educate on diabetic diet and diabetes nurse consultation to educate the patient on insulin administration and blood sugar monitoring at home.”Example #5: Pediatric RN Consults Nurse Leader Regarding Suspected Child Abuse• Situation:"Nurse Sherman, I am the emergency room RN-P assigned to care for S. Wilson, a six-year-old boy. I have some concerns I'd like to share with you and get your advice." "Scotty was brought to the emergency room this morning with complaints of severe stomach pain and weight loss."• Background:"Routine lab work showed signs of anemia, low calcium, and vitamin D deficiency. An abdominal x-ray was negative for any abnormalities."• Assessment:"I do not have a full health record to compare, but according to his mother, he 'just won't eat and is getting skinny.' When I performed the head-to-toe assessment on Scotty, I found several bruises of varying stages of healing in his back, both upper arms, and on the back of his legs. His mother told me he is clumsy. Scotty will not answer the simplest questions and when I try to engage him, his mother seems to take over the conversation."• Recommendation:"I would really like to have you and the pediatrician take a closer look at Scotty and see if you come to the same concerns as I did. If the situation warrants, I feel the office of Children and Family Services should be notified to evaluate the home and family situation for Scotty's safety. Do you agree?"Example #6: RN Giving Report to Another Nurse About Patient Suspected of Having Appendicitis• Situation:“Tyler Wilson is a 15-year-old Caucasian male brought to the ER with complaints of abdominal pain and fever.”• Background:“Tyler’s father reports he was awakened around 4 a.m. with Tyler complaining of unbearable pain in his stomach around his belly button. At that time, his temperature was 100.6.”• Assessment:“Tyler’s vital signs are currently T 101.6, R 24, P 94, BP 136/82, O2 98%. He continues to complain of pain but states it is more in the RLQ, with positive rebound tenderness in that area. Tyler has vomited twice in the last hour and states his stomach hurts with movement.”• Recommendation:“Lab results are pending. I have notified Dr. Michaels with a request to order a CT of the abdomen. Is there anything else you'd like to request or other suggestions for interventions?"As a new nurse, one of the most nerve-wracking things to do is giving a handoff report to another healthcare provider, be it the next oncoming nurse, the charge nurse, the nurse who covers you on break, the doctors, and the ancillary staff. It is nerve-wracking because you don’t want to miss important information, but you don’t want to give too much or too little information. Providing the right amount of information pertinent to each healthcare provider is what makes a handoff report great. Show
While I was in school, I thought it was a little silly to repeat the information that the instructor just gave m,e and I felt that I was doing it all wrong. But honestly, it’s good to repeat the information out loud, so you know what’s going on. SBAR is comprehensive and is great for the oncoming nurse. Here are the elements. S : Situation
B : Background
A : Assessment
R : Request
For example: S: This is Jane Doe, 78 year old female under Dr. So-And-So. A/O x 3 but forgetful. She has no allergies, not on isolation, and is a full code. B: She came in with pneumonia. Her past medical history includes COPD and diabetes. She came in yesterday and started on oxygen and antibiotics. A: (Vital signs) Her vital signs are stable. Afebrile. No pain. Current labs Her WBC is elevated. R: I recommend ID (infectious disease) consult on her.  How to give a good handoff report to other healthcare providersFor a doctor or PA/NP who is new to the patientDo a shortened SBAR with the situation, pertinent past medical history, pertinent physical assessment, trending labs if available, and recommendation. For a doctor or PA/NP who already knows the patientGive a shortened SBAR with the situation, any changes in vital signs, mental status, respiratory, GI, GU, lab work), and your recommendation. For the charge nurse
For the nurse covering your breakState the situation, code status, mental status, activity, diet, drips, and any abnormal vital signs that have stabilized or anything else to look out for and need to do. What should be included in an SBAR?SBAR Tool: Situation-Background-Assessment-Recommendation. S = Situation (a concise statement of the problem). B = Background (pertinent and brief information related to the situation). A = Assessment (analysis and considerations of options — what you found/think). What is the purpose of the SBAR communication tool ATI?The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team about a patient's condition.
What information is communication when using SBAR?Use SBAR to communicate any urgent or nonurgent patient info to other healthcare pros like doctors or therapists. Include: Conversations with physicians, physical therapists, or other professionals. In-person discussions and phone calls.
What is the first step in the SBAR communication technique?Each component of SBAR—situation, background, assess- ment, recommendation—provides a format for which to present information in a specific, organized way. The first step of the SBAR tool is stating the situation.
|
