Using The Information From Activities 1, 2, And 3

Using The Information From Activity 1 2 And 3 Write Out An End Of S

Using the information from Activity 1, 2, and 3, write out an end-of-shift report using the I-SBAR-R template or your own document. You should include the following:

• (S) Situation: What is the situation you are calling about? Identify self, unit, patient, room number. Briefly state the problem, what it is, when it started, and how severe.
• (B) Background: Pertinent background information related to the situation could include the following: The admitting diagnosis and date of admission, list of current medications, allergies, IV fluids, labs, most recent vital signs, lab results (date and time), previous test results for comparison, other clinical information, and code status.
• (A) Assessment: What is the nurse’s assessment of the situation?
• (R) Recommendation: What is the nurse’s recommendation, or what does he/she want?

Examples: notification that patient has been admitted, patient needs to be seen now, order change. Document the change in the patient’s condition and physician notification.

Citation: Kaiser Permanente. (n.d.). SBAR: Situation-background-assessment-recommendation. Institute for Healthcare Improvement.

Paper For Above instruction

End-of-shift reporting is a crucial component of nursing practice that ensures continuity of care, effective communication among healthcare team members, and patient safety. Utilizing the SBAR (Situation-Background-Assessment-Recommendation) communication framework enhances clarity and efficiency in reporting, especially during shift changes or patient handovers. Based on activities 1, 2, and 3, an effective end-of-shift report constructed with SBAR encompasses a comprehensive overview of the patient’s current status, relevant background information, clinical assessment, and specific recommendations or follow-up actions needed.

Introduction

The primary purpose of an end-of-shift report is to provide incoming nursing staff with a clear, concise, and accurate summary of the patient’s condition. Incorporating the SBAR format allows for structured communication, minimizing misunderstandings and omissions. This structured approach facilitates a systematic transfer of information, which is vital for maintaining high standards of patient safety and care quality.

Situation

The situation component initiates the communication by stating who the nurse is, the patient's identification (name and room number), and the reason for the report. For instance, "This is Nurse Jane Doe from Ward 3. I am reporting on Patient John Smith in Room 12. The patient’s condition has worsened over the last few hours, presenting with increased respiratory distress and a drop in oxygen saturation." Clearly defining the problem and its severity ensures the receiving team understands the urgency and nature of the situation.

Background

The background section provides relevant clinical history and contextual factors that influence the current situation. This includes the patient's admitting diagnosis (e.g., pneumonia), admission date, current medications, allergies, recent labs, and vital signs. For example, "Patient John Smith was admitted for pneumonia two days ago. His medications include antibiotics and bronchodilators. He is allergic to penicillin. His latest vital signs, taken an hour ago, show a temperature of 102°F, blood pressure of 130/80 mmHg, pulse 110 bpm, respiratory rate 24 breaths per minute, and oxygen saturation at 90% on 2L nasal cannula." Providing this background helps the receiving team understand baseline status and ongoing treatment plans.

Assessment

The assessment involves the nurse’s clinical judgment based on observed data and patient responses. It includes vital signs, physical findings, and any changes noticed. For example, "Upon assessment, the patient is demonstrably anxious, with increased respiratory effort, use of accessory muscles, and audible wheezing. His oxygen saturation has decreased from 94% to 90%, despite supplemental oxygen. Lung auscultation reveals diminished breath sounds and crackles in the right lower lobe."

Recommendation

Finally, the recommendation articulates what actions or interventions the nurse suggests or requests. It may include further assessment, notifying the physician, or requesting specific interventions. For example, "I recommend immediate assessment by the respiratory therapist, increased oxygen therapy, and physician notification for potential medication adjustment. The patient may require additional oxygen therapy or escalation of care."

Conclusion and Significance

Employing the SBAR framework in end-of-shift reporting enhances communication by providing a standardized method that reduces errors and omissions. It creates a clear pathway for important clinical information to be passed efficiently from one caregiver to another. This structured communication is aligned with patient safety goals promoted by healthcare accreditation agencies, including The Joint Commission and the Institute for Healthcare Improvement (Kaiser Permanente, n.d.).

Implications for Nursing Practice

Implementing SBAR in shift reports promotes accountability and ensures critical data are shared consistently. It fosters a culture of open communication, which is essential during high-pressure situations such as emergencies or unpredictable patient deterioration. Additionally, using SBAR supports multidisciplinary collaboration, ultimately enhancing patient outcomes and safety.

Conclusion

In summation, effectively utilizing the SBAR format during end-of-shift reports is integral to delivering safe, patient-centered care. By systematically sharing key information—situation, background, assessment, and recommendations—nurses can facilitate seamless continuity of care, minimize communication failures, and promote positive patient outcomes.

References

• Kaiser Permanente. (n.d.). SBAR: Situation-background-assessment-recommendation. Institute for Healthcare Improvement.
• Haig, K. M., Sutton, S., & Whittington, J. (2006). SBAR: A shared mental model for improving communication between clinicians. Joint Commission Journal on Quality and Safety, 32(3), 167-175.
• Collins, S., & Hart, K. (2014). Effective communication in nursing: Using the SBAR technique. Nursing Standard, 28(12), 55-59.
• Thomas, M., & McKinney, S. (2019). Enhancing shift-to-shift nurse communication with SBAR. Journal of Nursing Care Quality, 34(2), 124-130.
• Institute for Healthcare Improvement. (n.d.). SBAR Technique: Standardized Communication Tool. IHI.
• Johnson, K., & Smith, A. (2017). The impact of structured communication tools on patient safety. American Journal of Nursing, 117(9), 46-53.
• O’Daniel, M., & Rosenstein, A. H. (2008). Professional communication and team collaboration. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality.
• Manojlovich, M. (2010). The role of effective communication in patient safety. Critical Care Nurse, 30(4), 32-44.
• O’Daniel, M., & Rosenstein, A. (2008). Communication in health care: Enhancing patient safety through better teamwork. Agency for Healthcare Research and Quality.
• Gordon, G. H., et al. (2012). Nursing communication interventions and patient safety. Journal of Nursing Administration, 42(8-9), 378-383.