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Difficulty: HardCollaboration with Interdisciplinary Team

A registered nurse on a medical-surgical unit is contacting the neurointensivist regarding a client whose neurologic status has suddenly deteriorated. Arrange the nurse's statements in the correct chronological sequence to follow the SBAR (Situation, Background, Assessment, Recommendation) interprofessional communication protocol.

  1. 1This is the nurse caring for the client in room 312; I am calling because the client has suddenly developed right-sided hemiplegia and expressive aphasia.
  2. 2The client was admitted two days ago for a pulmonary embolism and is currently receiving a continuous intravenous heparin infusion.
  3. 3The client's Glasgow Coma Scale score has decreased from 15 to 11, the right pupil is sluggish, and vital signs show a blood pressure of 180/100 mm Hg.
  4. 4I need a provider to come evaluate the client immediately, and I request an order for a STAT non-contrast computed tomography (CT) scan of the head.

Answer

The correct sequence follows the standard SBAR protocol: Situation, Background, Assessment, and Recommendation.
The SBAR protocol is a structured communication tool designed to improve interprofessional collaboration and client safety. The sequence must begin with the Situation (the immediate problem), follow with the Background (relevant clinical history), transition to the Assessment (current objective findings), and conclude with the Recommendation (the requested action). Following this specific order ensures that critical information is conveyed logically and urgently, especially when advocating for a client experiencing a sudden neurologic decline.

Step-by-Step Solution

1
Identify the 'Situation' statement.
Select the statement identifying the immediate concern (right-sided hemiplegia and aphasia).
The SBAR framework begins by clearly stating the current, acute problem that requires interdisciplinary attention.
2
Identify the 'Background' statement.
Select the statement detailing the admission for a pulmonary embolism and the continuous heparin infusion.
After stating the problem, the nurse provides clinical context, including relevant medical history and ongoing treatments that may impact the acute change.
3
Identify the 'Assessment' statement.
Select the statement with the GCS score, pupil response, and blood pressure.
The nurse then provides current, objective clinical data to support the situation and provide the provider with measurable metrics.
4
Identify the 'Recommendation' statement.
Select the statement requesting an immediate evaluation and a head CT.
The communication concludes with a clear request or proposed action plan to guide the next steps in client care.

Key Concept

Collaboration with Interdisciplinary Team
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Topics

Collaboration with Interdisciplinary Team

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