Choose an experience from your nursing practice. Using the “SBAR” template, explain the situation in detail, followed with background information. Then explain your immediate assessment and recommendations you have for the provider. Include the following in the “SBAR” template: APA style is not required, but solid academic writing is expected. This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. You are not required to submit this assignment to LopesWrite.
Title: Application of SBAR Communication Model in Nursing Practice
Introduction:
The Situation-Background-Assessment-Recommendation (SBAR) communication model has gained importance in healthcare communication, facilitating efficient and effective communication among healthcare professionals. This model is particularly useful in nursing practice, where clear and concise communication is essential for patient safety and care coordination. This paper will discuss the application of the SBAR template in describing a specific nursing practice experience, followed by an analysis of the situation, background information, immediate assessment, and recommendations.
Situation:
During a night shift at a busy surgical unit, I encountered a patient with tachycardia, severe respiratory distress, and a history of congestive heart failure (CHF). The patient’s vital signs depicted a heart rate of 120 beats per minute, blood pressure of 170/95 mmHg, respiratory rate of 28 breaths per minute, oxygen saturation of 90% on room air, and crackles in bilateral lung fields upon auscultation. The patient was agitated, visibly anxious, and complaining of extreme difficulty in breathing. This situation required immediate action and effective communication with the healthcare team.
Background:
The patient, Mr. X, is a 70-year-old male with a medical history of CHF, hypertension, and diabetes mellitus type 2. He was admitted to the surgical unit postoperatively after having undergone a laparoscopic cholecystectomy earlier that day. Mr. X’s surgical procedure was uneventful, and he was recovering well until approximately four hours post-surgery when he developed the aforementioned symptoms. The patient has a known history of fluid retention related to his CHF and has been on a strict daily diuretic regimen, which had previously proven effective in managing his symptoms. However, during his hospital stay, Mr. X experienced some medication non-adherence due to nausea and vomiting, leading to concerns regarding his fluid balance.
Immediate Assessment:
Upon recognition of Mr. X’s deteriorating clinical condition, I promptly assessed his oxygen saturation level and provided supplemental oxygen via a nasal cannula at 4 liters per minute. An IV line was established, and a pulse oximeter was attached for continuous monitoring of oxygen saturation and heart rate. The patient’s respiratory status remained compromised despite oxygen administration, and his tachycardia persisted. I auscultated crackles bilaterally in the lung fields, suggestive of pulmonary edema, and noticed the patient’s feet had mild pitting edema. I also observed that his urine output had been drastically reduced over the past few hours. Based on these findings, it was apparent that Mr. X’s fluid balance was disturbed, likely contributing to his worsening symptoms.
Recommendations:
To ensure prompt and appropriate intervention for Mr. X, I determined that it was crucial to communicate this situation effectively to the healthcare provider. I used the SBAR communication model to convey the relevant information to the provider, ensuring clear and concise transmission of critical data. In my communication, I highlighted Mr. X’s symptoms of tachycardia, severe respiratory distress, decreased urine output, crackles in lung fields, and the presence of peripheral edema. Simultaneously, I emphasized the patient’s medical history of CHF and recent non-adherence to his diuretic regimen, which could potentially account for his fluid overload. Furthermore, I expressed the need for immediate medical intervention and recommended establishing closer hemodynamic monitoring, considering diuresis, and initiating appropriate pharmacological interventions to manage Mr. X’s acute respiratory distress and suspected pulmonary edema.
Conclusion:
The SBAR communication model provides a structured approach to effectively communicate crucial information between healthcare professionals, particularly in situations that require prompt action. This nursing practice experience highlights the application of the SBAR template for communicating the situation, background information, immediate assessment, and recommendations to a healthcare provider in a concise and organized manner. By using this communication tool, nursing professionals enhance patient safety, facilitate care coordination, and promote effective decision-making.