Situation-Background-Assessment-Recommendation (SBAR) format

Situation-Background-Assessment-Recommendation (SBAR) format using the Situation-Background-Assessment-Recommendation (SBAR) format. Please note that this assignment is for coursework to be done. SBAR TEMPLATE – to submit issues of concern to NNLC The SBAR (Situation-Background-Assess ment-Recommendation) technique prov ides a framework for communication between members of the health care team. Although this tech nique was original developed to target a patient-centered condition, the NNLC will implement this technique to comm unicate and address critical issues to support immediate attention and action by the committee. This SBAR tool was developed by Kaiser Permanente. S Situation: What is the situation you are writing about? • Identity self, health care site, area, title, date, etc. • Briefly state the problem/issue, what is it, when it happened or started, and how severe. EXAMPLE: Author: Sharon Feldstein, Chair-Albuquer que Area Council of Nurse Executives Date: July 10, 2008 Situation: Public Health Nursing Funded Positions B Background Pertinent background information related to the situation could include the following: • The history of problem/issue, the date of the problem/issue. • List of current situations. • Most recent occurrences. • National standards, policy, regulations, standards, requirements. EXAMPLE: Background: At the John P. Morgan Health Center, during FY 200 8, the Public Health Nursing (PHN) department consisted of 5 PHNs. During this time, 3 PHNs were detailed to outpatient on average 40% of their time and supervised by the Clinical Director, which decreas ed the PHN Provider Productivity significantly. The IHS Public Health Nursing scope of Practice is designed to build healthy communities by promoting healthy behaviors and lifestyles through provision of care based on a primary prevention public health model. The American Nurses Association Scope of Practice Model describes the practice of the PHN as placing emphasis on primary prevention in all health promotio n & health protection strategies with the focus on population level outcome. The GPRA objective related to the Health Promotion & Disease Prevention correlates directly with the PHN program funding & is most effective with the PHN planning, developing, & supporting systems in the community setting. PHN visits are done primarily in the home, PHN specialty clinics, PHN office settings, school & community sites with primary prevention as the focus for meeting the IHS mission. PHN core services are divided into direct & indirect ca re activities listed in the RRM document with do not cover services defined in the clinic settings supervised by another discipline. The standard PHN position description, which is held at a minimum educational level of BSN, describes PHN supervision directly under the DPHN & with the scope of community focused primary prevention. A Assessment What is your assessment of the situation? EXAMPLE: Assessment: A lack of adherence to the defined standar ds identified in the PHN PD. Poor use of PHN services in addressing public health issues. Disregard for IHS line-item funded PHN position. R Recommendation What is your recommendation or what do you want (say what you want done)? EXAMPLE: Recommendation: NNLC will suppor t the following recommendations- 1) The PHN funded positions must follow PHN job description duties with education qualifications adhered to & functions with primary prevention focus under the direction of the DPHN; therefore, the utilization of the PHN staff in th eir highest potential capability. 2) PHN funded positions will no long er be detailed for non PHN-duties. NNLC reviewed on: _______________________________(date) Recommendations were made on: ___________________ (date) Was this forwarded to the Chief Nurse? ____ Yes; ____ No. If so, on what date: _____________________. Health History and Examination Health Assessment of the Head, Neck, Eyes, Ears, Nose, Mouth, Throat, Neurological System, and the 12 Cranial Nerves Skin, Hair, Nails, Breasts, Peripheral Vascular System, Lymphatics, Thorax, Heart, Lungs, Musculoskeletal, Gastrointestinal, and Genitourinary Systems Save this form on your computer as a Microsoft Word document. You can expand or shrink each area as you need to include relevant data for your client. Student Name:JANE DOE    Date: Client/Patient Initials:    Sex:F    Age:    63 Occupation of Client/Patient:RETIRED Health History/Review of Systems (Complete and systematic review of systems) Neurological System (headaches, head injuries, dizziness, convulsions, tremors, weakness, numbness, tingling, difficulty speaking, difficulty swallowing, etc., medications): SEIZURE DISORDER, KEPPRA 500 MG 1 TABLET TWICE DAILY Head and Neck (pain, headaches, head/neck injury, neck pain, lumps/swelling, surgeries on head/neck, medications): NA Eyes (eye pain, blurred vision, history of crossed eyes, redness/swelling in eyes, watering, tearing, injury/surgery to eye, glaucoma testing, vision test, glasses or contacts, medications): CATARACT SURGERY TO LEFT EYE DONE IN 2013 Ears (earache or other ear pain, history of ear infections, discharge from ears, history of surgery, difficulty hearing, environmental noise exposure, vertigo, medications): NO PROBLEM Nose, Mouth, and Throat (discharge, sores or lesions, pain, nosebleeds, bleeding gums, sore throat, allergies, surgeries, usual dental care, medications): FULL DENTURE Skin, Hair and Nails (skin disease, changes in color, changes in a mole, excessive dryness or moisture, itching, bruising, rash or lesions, recent hair loss, changing nails, environmental hazards/exposures, medications) NO PROBLEM Breasts and Axilla (pain or tenderness, lumps, nipple discharge, rash, swelling, trauma or injury to breast, mammography, breast self-exam, medications): MAMMOGRAM EVERY 2 YEARS Peripheral Vascular and Lymphatic System (leg pain, cramps, skin changes in arms or legs, swelling in legs or ankles, swollen glands, medications):NO PAIN Cardiovascular System (chest pain or tightness, SOB, cough, swelling of feet or hands, family history of cardiac disease, tire easily, self-history of heart disease, medications):HYPERTENSION SINCE 2005, TAKE LISINOPRIL 10 MG DAILY Thorax and Lungs (cough, SOB, pain on inspiration or expiration, chest pain with breathing, history of lung disease, smoking history, living/working conditions that affect breathing, last TB skin test, flu shot, pneumococcal vaccine, chest x-ray, medications): YEARLY FLU VACCCINE LAST GIVEN 10/14/14 AND PNEUMONIA VACCINE EVERY 5 YEARS LAST  GIVEN 1/1/2013 Musculoskeletal System (joint pain; stiffness; swelling, heat, redness in joints; limitation  of movement; muscle pain or cramping; deformity of bone or joint; accidents or trauma to bones; back pain; difficulty with activity of daily living, medications): TOTAL RIGHT KNEE REPLACEMENT IN 11/1/14 PERCOCET 5/325 MG 2 TABLETS ORALLY EVERY 8 HOURS AS NEEDED FOR PAIN Gastrointestinal System (change in appetite – increase or loss; difficulty swallowing; foods not tolerated; abdominal pain; nausea or vomiting; frequency of BM; history of GI disease, ulcers, medications): REGULAR BM AND VOIDING PATTERNS Genitourinary System (recent change, frequency, urgency, nocturia, dysuria, polyuria, oliguria, hesitancy or straining, urine color, narrowed stream, incontinence, history of urinary disease, pain in flank, groin, suprapubic region or low back): RESIDENT DENIES ANY PROBLEM Physical Examination (Comprehensive examination of each system. Record findings.) Neurological System (exam of all 12 cranial nerves, motor and sensory assessments): PATIENT IDENTIFIED PRODUCT GAVE TO SMELL PATIENT ACUITY IS WNL AND ABLE TO IDENTIFY COLOR  AS WELL AS MOVE EYES PATIENT ABLE TO FOLLOW FINGER WHILE KEEPING HEAD STILL PATIENT ABLE TO CLENCH IS TEETH TOGETHER PATIENT ABLE TO KEEP EYES CLOSES AGAINST RESISTANT PATIENT IDENTIFIED LOUDER SOUND OVER EAR VERSUS MASTOID PROCESS PATIENT GAG WHEN ARCHES OVER PHARYNX WAS TOUCHED PATIENT ABLE TO SPEAK CLEARLY PATIENT ABLE TO SHUG SHOULDER AGAINST RESISTANT PATIENT ABLE TO STICK TONGUE OUT STRAIGHT Head and Neck (palpate the skull, inspect the neck, inspect the face, palpate the lymph nodes, palpate the trachea, palpate and auscultate the thyroid gland): NO PROBLEM NOTED Eyes (test visual acuity, visual fields, extraocular muscle function, inspect external eye structures, inspect anterior eyeball structures, inspect ocular fundus): PATIENT ACUITY IS WNL, ABLE TO IDENTIFIED COLOR AND MOVE EYES WITHOUT MOVING THE HEAD Ears (inspect external structure, otoscopic examination, inspect tympanic membrane, test hearing acuity):HEARING ACUITY IS WNL WITH SYMMETRY ON BOTH SIDES Nose, Mouth, and Throat (Inspect and palpate the nose, palpate the sinus area, inspect the mouth, inspect the throat): ORAL MUCOSA  IS WNL BUT WEARS FULL DENTURE Skin, Hair and Nails (inspect and palpate skin, temperature, moisture, lesions, inspect and palpate hair, distribution, texture,  inspect and palpate nails, contour, color, teach self-examination techniques): WNL Breasts and Axilla (deferred for purpose of class assignment) Peripheral Vascular and Lymphatic System (inspect arms, symmetry, pulses; inspect legs, venous pattern, varicosities, pulses, color, swelling, lumps): RADIAL AND PEDAL PULSES IDENTIFIED Cardiovascular System (inspect and palpate carotid arteries, jugular venous system, precordium heave or lift, apical impulse; auscultate rate and rhythm; identify S1 and S2, any extra heart sounds, murmur): S1 AND S2 IDENTIFIED, NO JUGULAR VEIN DISTENTION NOTED Thorax and Lungs (inspect thoracic cage, symmetry, tactile fremitus, trachea; palpate symmetrical expansion;, percussion of anterior, lateral and posterior, abnormal breathing sounds): BREATHING EVEN AND UNLABORED WITH CLEAR LUNG SOUNGS  BILATERALLY Musculoskeletal System (inspect cervical spine for size, contour, swelling, mass, deformity, pain, range of motion; inspect shoulders for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect elbows for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect wrist and hands for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect hips for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect knees for size, color, contour, swelling, mass, deformity, pain, range of motion; inspect ankles and feet for size, color, contour, swelling, mass, deformity, pain and range of motion): Gastrointestinal System (contour of abdomen, general symmetry, skin color and condition, pulsation and movement, umbilicus, hair distribution; auscultate bowel sound;, percuss all four quadrants; percuss border of liver; light palpation in all four quadrants– muscle wall, tenderness, enlarged organs, masses, rebound tenderness, CVA tenderness): BOWEL SOUNDS PRESENTS IN ALL QUADRANTS ABD SOFT TO TOUCH AND NONTENDER REGULAR BM Genitourinary System (deferred for purpose of this class) FHP Assessment Cognitive-Perceptual Pattern: Nutritional-Metabolic Pattern: EAT 3 MEALS PER DAY. PREPARE BYSELF, ALL FOOD TYPES Sexuality-Reproductive Pattern: MENSES STARTED ABOUT 15 YRS AND ENDED 51 YRS Pattern of Elimination REGULAR BM AND VOIDING PATTERNS Pattern of Activity and Exercise: WATER EXECRISE 3 TIMES WEEKLY Pattern of Sleep and Rest: 7 TO 8 HOURS OF SLEEP NIGHTLY Pattern of Self-Perception and Self-Concept: BLESSED TO BE ALIVE AND Summarize Your Findings (Use format that provides logical progression of assessment.) Situation (reason for seeking care, patient statements): Background (health and family history, recent observations): Assessment (assessment of health state or problems, nursing diagnosis): Recommendation (diagnostic evaluation, follow-up care, patient education teaching including health promotion education):