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:
The patient is alert and oriented to person, place, and time. He expresses understanding of his discharge instructions, which include:
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:
Monitor Jeremy Marvin’s pain level regularly and administer morphine as needed.
Assist with ambulation and encourage mobility exercises to enhance recovery.
Review the discharge instructions with the patient again before his potential discharge tomorrow morning.
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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