SBAR Nurse Bedside Shift Report
I. Summary
Prepared by: [YOUR NAME]
Company: [YOUR COMPANY NAME]
Date: [DATE]
This expanded plan emphasizes holistic care for [Patient's Name], integrating nutritional support alongside pain management, mobility enhancement, and respiratory care. It ensures comprehensive support for the patient's recovery journey and promotes collaboration among healthcare providers to achieve optimal outcomes.
II. Patient Information
III. SBAR Table
SBAR Component | Details |
|---|
Situation | [Patient's Name] is a 55-year-old male patient admitted for post-operative care following a knee replacement surgery. He is currently stable but requires ongoing monitoring and pain management. |
Background | Medical History: Hypertension, controlled with medication. No known allergies.
Surgical History: Knee replacement surgery performed yesterday without complications. |
Assessment | General Condition: Alert and oriented x3, complains of moderate pain at surgical site (rated 5/10).
Vital Signs: BP 130/80, HR 80 bpm, RR 18/min, SpO2 98% on room air.
Pain Assessment: Reports pain localized to right knee; managed with PRN analgesics (last dose of acetaminophen administered at 1800 hours). |
Recommendations | • Continue monitoring vital signs every 4 hours and document pain scores.
• Administer PRN acetaminophen for pain as needed, ensuring pain is adequately controlled (pain goal < 4/10).
• Encourage deep breathing exercises and leg exercises as tolerated to prevent complications such as atelectasis and deep vein thrombosis. |
IV. Family Involvement
During the shift, family members have been actively involved in [Patient's Name]'s care. They have been supportive and engaged, assisting with comfort measures and encouraging mobility. Discussions included updates on pain management and rehabilitation progress, ensuring they are well-informed partners in the recovery process.
V. Plan
Continue with the current care regimen focused on effective pain management, promoting mobility, and maintaining respiratory hygiene. Nursing staff will collaborate closely with physical therapy to facilitate early mobilization and functional recovery. Updates will be provided to the patient and family regarding progress and any changes in the care plan as needed.
Additionally, it is recommended to initiate dietary consultations to ensure optimal nutrition for healing and recovery. Encouraging adequate fluid intake and balanced meals will support the patient's overall well-being during the rehabilitation process.
[Your Name], RN
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