A nurse is providing change-of-shift report to another nurse for a client using the Introduction, Situation, Background, Assessment and Recommendation (ISBARR) communication tool. Which of the following information should the nurse include as part of the situation component of this communication tool?

Explanation:

A. Medical condition:

Including the client's medical condition in the Situation component of the ISBARR communication tool is important because it provides an overview of the client's health status. This may include a brief description of the primary diagnosis, current symptoms, or any significant changes in the client's condition since the last shift. It helps the receiving nurse understand the context and urgency of the report.

B. Treatment:

While treatment information is crucial for providing comprehensive care to the client, it is typically included in the Background or Assessment components of the ISBARR communication tool. The Situation component focuses on summarizing the client's current status rather than detailing specific treatments or interventions.

C. Vital signs:

Vital signs, such as heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation, are essential clinical data. However, they are usually included in the Assessment component of the ISBARR communication tool, where the nurse provides a detailed assessment of the client's physiological parameters and trends.

D. List of medications:

Similar to treatment information, a list of medications is typically included in the Background or Assessment components of the ISBARR communication tool. It is important for the receiving nurse to know what medications the client is taking, including doses, frequencies, and any recent changes, but this information is more detailed and specific than what is typically included in the Situation component.

Explanation:

A. "The client has developed drooping facial features."

This statement provides specific information about a recent change in the client's condition, which is relevant background information. It helps the provider understand one of the key reasons for the communication.

B. "The client may benefit from a neurology consult."

While suggesting a neurology consult is a potential recommendation (R) in the SBAR tool, it is not part of the Background (B) component. Background information typically focuses on factual data about the client's history, current condition, and pertinent details relevant to the situation.

C. "The client is disoriented and pupils are slow to respond to light."

Similar to option B, this statement describes the client's assessment findings and current condition rather than providing background information. It would be more appropriate in the Assessment (A) component of the SBAR tool.

D. "The client has a history of hypertension."

This statement provides relevant background information about the client's medical history, specifically their history of hypertension. Including this information in the Background component helps the provider understand the client's baseline health status, which is important for evaluating the current situation.