It is crucial to obtain a strong nurse report before beginning your shift. In addition to the nurse, the patient also benefits from it. A different nurse who will be taking over the patient’s care receives the nursing report at the conclusion of the first nurse’s shift.
Due to patient privacy, nursing reports are typically provided in an area where others cannot hear them. Try to speak quietly so that other patients and family members can’t hear you if you have to deliver a report outside of a patient’s room.
It is highly suggested that nurses utilize the SBAR tool as guidance while giving reports. Situation, Background, Assessment, and Recommendation is referred to as SBAR.
The SBAR tool is a piece of paper that is typically kept in the patient’s chart and contains a summary of the patient’s history, current situation, significant medical history, allergies, doctors the patient has seen, etc. It is often updated by every shift and scribbled on in pencil.
This straightforward piece of paper can help direct nurses who are giving reports, as you can see from the SBAR above. The arriving nurse should ask the reporting nurse crucial questions about the patient’s status that might not be covered in the SBAR despite the fact that it is a fantastic tool.
- Does that patient have any family? is one of the questions to ask during a nursing report.
- Who is the patient’s main point of contact in the event of an emergency?
- Are there any tests that the patient needs to be NPO for?
- Does the patient require help eating, taking a shower, or going to the restroom?
- How does the patient consume her medications? either needs to be swallowed or crushed?
- How are the new meds being tolerated by the patient? Any significant changes in heart rate, blood pressure, etc.?
- What PRN drugs is the patient taking?
- Is the patient hurting? How can we manage the pain? Medications, and if so, what kind? When will it be due again?
- Does the patient need a nurse to leave the floor for testing?
- Is the patient being monitored via telemetry or not?
- Does the patient go outside after leaving the room?
- How well is the patient able to walk unassisted?
- When was the patient’s last time getting out of bed?
- Does the patient have trouble seeing or hearing?
- Exist any unfinished medical orders that need to be fulfilled?
- Has the patient signed an informed consent form? Are the IV tubing dates still valid or do they need to be updated today (if the patient is undergoing surgery)?
- Is next Dressing Change Due for Wound Care?
- Any requests or worries regarding the patient?
The questions listed above may or may not be included in the SBAR but are still important to always be aware of. Always remember to ask questions after receiving reports. The greater care you can give to your patient, the more you will know.