A nurse is giving change-of-shift report using the SBAR technique about a client who has a traumatic brain injury. When reporting information about the client, which of the following should the nurse include in the situation segment of SBAR?

Explanation:

A. Battery: Battery refers to intentional harmful or offensive touching without consent. In the context of healthcare, it usually involves physical contact or procedures performed without the patient's consent. An inadvertent medication error, even if it causes harm, does not typically constitute battery unless there was an intentional act of administering the wrong medication against the patient's will.

B. Assault: Assault is the threat of harmful or offensive contact. It involves creating a reasonable apprehension of imminent harmful or offensive contact in the patient's mind. An inadvertent medication error, while it may cause harm, does not typically constitute assault unless there was an intentional threat of harm made to the patient.

C. Abuse: Abuse involves the intentional mistreatment or harm of another person. An inadvertent medication error is not considered abuse unless there was an intentional act to harm the patient.

D. Malpractice: Malpractice refers to professional negligence or failure to provide the standard of care expected in a particular profession, such as nursing. In the scenario described, the inadvertent medication error resulting in a severe allergic reaction and prolonging the client's hospitalization could be considered a case of malpractice. The nurse failed to meet the standard of care expected in administering medications safely, leading to harm to the patient.

Explanation:

A. Avoid touching the client:

While it's essential to be gentle and respectful when touching an unresponsive client, avoiding all touch may not be appropriate. Touch can be a comforting and reassuring gesture, and many clients at the end of life benefit from gentle touch, such as holding their hand or providing a gentle massage.

B. Continue to talk to the client as if they are awake:

Talking to the client, even if they are unresponsive, is encouraged. Hearing is often the last sense to diminish, and talking to the client in a soothing and reassuring manner can provide comfort and a sense of presence. The nurse should speak calmly and compassionately, addressing the client by name and providing updates on care activities.

C. Limit the client's visitors to one at a time:

Limiting the number of visitors and controlling the environment can help maintain a calm and peaceful atmosphere for the client. However, the specific number of visitors allowed at a time may vary based on the client's preferences, cultural considerations, and facility policies. It's important to respect the client's wishes regarding visitors while ensuring their comfort and well-being.

D. Whisper when talking in the client's room:

Whispering may not be necessary unless the client is particularly sensitive to loud noises. Speaking in a calm and gentle tone is generally more appropriate, as it allows the client to hear clearly without causing unnecessary strain or confusion.