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:

1. Monitor Jeremy Marvin’s pain level regularly and administer morphine as needed.

2. Assist with ambulation and encourage mobility exercises to enhance recovery.

3. Review the discharge instructions with the patient again before his potential discharge tomorrow morning.

4. 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.

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