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SBAR Shift Report revised 08-30-22 (1)
Nursing Pharmacology
Keiser University
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SBAR Shift Report
Initials ________________ Age ___________ Weight _______________ Room # ___________
Situation
Date of admission: ___________________ Chief Complaint/Diagnosis/Procedure ______________________________________________________ Allergies _____________________________________________________________________________ Code Status Full______ DNR______ Infection _____________________________________________________________________________ [ ] MRSA [ ] VRE Isolation: [ ] contact [ ] droplet [ ] airborne [ ] immunocompromised Antibiotics: _________________________________________________________________________ Fall Risk ________________ Bed Alarm ______________________________
Background
Medical History _________________________________________________________________________
Surgical History _________________________________________________________________________ EKG __________________________________________________________________________________ Na Cl Bun Hgb Ca Labs K HCO3 Cr Glucose WBC HCT PLT PT INR PTT Mg Phos
Assessment
Neuro A & O x _____ PERRLA _____ [ ] confused [ ] forgetful [ ] anxious ______________________ Pain: ____:10 Where ____________ Medicated ____________________ last dose __________________ Recommendations ________________________________________________________________________
Cardiac HR _______ Rhythm ___________ Pacemaker ________ B/P __________ Tele ___________ Pulses ___________________ Edema ____________________ Calf Pain ___________________________ Meds __________________________________________________________________________________ DVT prophylaxis ________________________________________________________________________ Recommendations ________________________________________________________________________
Respiratory: Rate ______ 02 Delivery ________ 02% sat ______ treatments_______________________ Lung sounds ____________________ [ ] SOB [ ] cough ______________ secretions __________________ Recommendations ________________________________________________________________________
GI: Diet __________________________ Glucose POC ______________ Insulin ___________________ Appetite ______________________ Problems ____________________ LBM ____________________ Recommendations ________________________________________________________________________
GU: Foley placed ___________ BRP ___________ Dialysis ____________/ Access __________________ I & O ________________________ ________________________________________________________ Recommendations ________________________________________________________________________
Skin: __________________________________________________________________________________ IV: Site: __________ Date of IV: ____________ Gauge: ______ IVF/rate: _______________________
MEDICATIONS
Time Dose Route Name Indication
Prioritization
Priority Assessments Priority Potentials & Actual Complications
2.
2.
3.
3.
Priority Nursing Implications 1.
Priority Lab Tests/Diagnostics 1. 2.
2. 3.
Priority Medications 3. 1.
2.
Priority Interventions 1. 3.
- Priority Education/Discharge Issues
3.
2.
3.
Care Plan
NURSING CARE PLAN (Pick 2 Actual and 1 Risk)
Nursing Diagnosis #1:
Expected Outcome: By the end of the shift the patient will______________________________.
Interventions: 1.
Nursing Diagnosis #2:
Expected Outcome: By the end of the shift the patient will_______________________________.
Interventions: 1.
Nursing Diagnosis #3:
Expected Outcome: By the end of the shift the patient will_______________________________.
Interventions: 1.
SBAR Shift Report revised 08-30-22 (1)
Course: Nursing Pharmacology
University: Keiser University
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