SBAR for Nurse Handoff
SBAR for Nurse Handoff
Date: September 26, 2050
I. Situation
Patient Jeremy Marvin, a 67-year-old male, is being transferred to the night shift nurse. He is currently in Room 204 following a right hip replacement. His pain level is at a 4/10 on the numerical pain scale, manageable with morphine every 4 hours as needed. The patient has shown signs of increased mobility but requires assistance with ambulation.
II. Background
Jeremy Marvin has a history of hypertension and type 2 diabetes, which are well-managed. He was admitted to [Your Company Name] on September 24, 2050, for a surgical procedure. His past medical history includes:
|
Condition |
Details |
|---|---|
|
Hypertension |
Well-controlled |
|
Type 2 Diabetes |
On metformin |
|
Previous Surgeries |
Appendectomy in 2010 |
The patient has been stable since surgery, with no complications reported. All pre-operative assessments were within normal limits, and post-operative recovery has been uneventful.
III. Assessment
Currently, Jeremy Marvin’s vital signs are as follows:
-
Blood Pressure: 130/85 mmHg
-
Heart Rate: 78 bpm
-
Respiratory Rate: 18 breaths/min
-
Temperature: 98.6°F
The patient is alert and oriented to person, place, and time. He expresses understanding of his discharge instructions, which include:
-
Continue with prescribed medications
-
Follow-up with Dr. Smith in one week
The dressing on his surgical site appears clean and dry, with no signs of infection.
IV. Recommendation
For the night shift, I recommend the following actions:
-
Monitor Jeremy Marvin’s pain level regularly and administer morphine as needed.
-
Assist with ambulation and encourage mobility exercises to enhance recovery.
-
Review the discharge instructions with the patient again before his potential discharge tomorrow morning.
-
Ensure the night shift nurse performs a thorough assessment upon receiving the patient to identify any changes in condition.
For any urgent issues, please feel free to reach out to me via email at [Your Email] or contact the nursing supervisor at [Your Company Number].
Thank you for your attention to this patient’s care.
