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. Right communication:

This refers to providing clear and concise instructions to the assistive personnel regarding the delegated task. Effective communication ensures that the AP understands the task, its objectives, any limitations or special considerations, and the expectations regarding its completion. Clear communication helps prevent misunderstandings and promotes safe and efficient task execution.

B. Right room:

This choice does not directly relate to the five rights of delegation. The "right room" concept may refer to ensuring that the environment or room where care is provided is appropriate, safe, and conducive to the task being performed. While environmental factors are important in healthcare, they are not part of the specific rights of delegation.

C. Right time:

The "right time" aspect of delegation involves considering the timing of the task within the overall care plan. It includes assessing whether the task should be performed immediately, at a specific time, or within a particular timeframe. Delegating tasks at the right time ensures that they align with the client's needs and the overall care schedule.

D. Right documentation:

This refers to documenting the delegation process, including details such as the delegated task, the personnel involved, any specific instructions or limitations provided, and the outcomes or results of the task. Documentation is crucial for accountability, continuity of care, and legal purposes, ensuring that there is a record of who performed the task and how it was carried out.

Explanation:

A. Data collection:

Data collection is the initial step of the nursing process where the nurse gathers information about the client's health status, including physical, psychological, social, and environmental factors. This involves conducting assessments, obtaining medical histories, performing physical exams, reviewing diagnostic tests, and gathering information from the client, family members, and other healthcare providers. In the scenario, data collection would involve gathering information about the client's postoperative condition, recovery progress, functional abilities, support system, home environment, and any other relevant factors that would influence the discharge planning process.

B. Evaluation:

Evaluation is the step of the nursing process where the nurse assesses the client's response to interventions, measures progress toward goals, and determines the effectiveness of the care provided. It involves comparing the client's actual outcomes with expected outcomes, identifying any deviations or areas needing improvement, and making adjustments to the care plan as necessary. In the scenario, evaluation would occur after the implementation of the discharge plan to assess the client's readiness for discharge, the achievement of goals, and the overall success of the interventions implemented.

C. Planning:

Planning is the phase of the nursing process where the nurse, in collaboration with the client, family, and healthcare team members, develops a comprehensive plan of care based on the collected data and identified needs. This includes setting priorities, establishing expected outcomes and goals, determining appropriate interventions, creating a timeline for implementation, and coordinating resources and services. In the scenario, planning involves working with the social worker and physical therapist to develop a discharge plan that addresses the client's postoperative needs, ensures continuity of care, promotes recovery, and supports a smooth transition from the healthcare facility to the home or next level of care.

D. Implementation:

Implementation is the phase of the nursing process where the nurse carries out the interventions outlined in the care plan. This involves putting the plan into action, providing direct care, educating the client and family, coordinating services, monitoring progress, and advocating for the client's needs. In the scenario, implementation would occur as the nurse, along with the social worker and physical therapist, initiates the discharge plan, arranges for services and resources, provides education and instructions to the client and family, and ensures that all necessary preparations are made for the client's transition from the hospital.