Share This Link

List of medications: A medication list provides background clinical information about the client’s treatment history or ongoing therapies. This belongs in the Background section (the “B” in ISBARR), not in the Situation, which should only include the immediate concern or clinical issue that triggered the report.

Treatment: Current treatments or interventions (such as oxygen therapy, IV fluids, or wound care) are important but are usually included in the Assessment or Recommendation areas. They do not represent the immediate “snapshot” of why you’re calling or handing off care. Therefore, they are not part of the Situation section.

Vital signs: Vital signs are pieces of objective assessment data, typically included in the Assessment section to support the seriousness of the situation. While V/S can help describe the condition, they are not the situation itself, so they don’t fit in the Situation component.

Decreased blood pressure: Blood pressure increases during fight-or-flight due to vasoconstriction, increased heart rate, and increased cardiac contractility. These changes help direct more blood to vital organs and muscles, enabling a rapid physical response.

Bronchial airway constriction: The sympathetic response actually dilates the bronchioles, allowing more air to enter the lungs to support increased oxygen demand. Bronchial constriction occurs in parasympathetic states, not during fight-or-flight.

Hypoglycemia: In a fight-or-flight response, the adrenal glands release epinephrine and cortisol, which stimulate glycogenolysis and gluconeogenesis. This results in increased blood glucose, not hypoglycemia, ensuring the muscles have an immediate energy source.

Turn on the television in the client's room: Turning on the TV introduces distracting noise and stimulation, which can make learning more difficult. Clients with visual impairment rely more heavily on auditory input; background noise competes with this and reduces comprehension.

Use a loud tone of voice: Visual impairment does not equate to hearing impairment. Raising your voice unnecessarily may be perceived as rude, condescending, or startling. Effective teaching involves speaking clearly, slowly, and respectfully at a natural tone.

Identify your presence by tapping the client's arm: Touching the client without warning can be startling and is inappropriate. Best practice is to announce yourself verbally upon entering the room and explain what you are going to do before touching the client. Verbal cues support independence and trust.

Dysphagia: Dysphagia refers to difficulty swallowing and is related to disorders of the esophagus or oropharynx, not the colon. Diverticulitis affects the large intestine (usually the sigmoid colon) and has no pathophysiological link to dysphagia.

Ulcerative colitis: Ulcerative colitis is a separate chronic inflammatory bowel disease unrelated to diverticulitis. One does not cause the other. UC affects the mucosal layer of the colon, while diverticulitis involves inflamed or infected diverticula.

Crohn's disease: Crohn’s disease is another type of inflammatory bowel disease, distinct from diverticulitis. It is not a complication of diverticulitis, and the two conditions have different etiologies and treatments.

Decreased tinnitus: Tinnitus (ringing, buzzing) is more commonly reported or perceived with advancing age. It often results from cumulative cochlear hair cell damage, noise exposure, or age-related sensorineural hearing loss (presbycusis), not a decrease in tinnitus.

Decreased thickness of tympanic membranes: The tympanic membrane and middle ear structures typically become less elastic and may thicken or stiffen with age, leading to reduced mobility and conduction of sound; they do not become thinner. The net effect is often decreased transmission of sound, particularly low-frequency conduction changes.

Decreased ear wax: Cerumen production often changes with age: earwax can become drier and may accumulate because older adults produce less oily secretions and hair/skin changes occur. Clinically, impaction or altered cerumen consistency is more common, not a meaningful decrease that improves hearing.

Open shades on windows in the client's room to provide direct lighting: While adequate lighting is important, direct bright light or glare (especially from uncovered windows or unshielded lamps) can worsen vision for many with low vision. Use diffuse, even lighting and position light sources to reduce glare and shadows.

Speak loudly when talking to the client: Visual impairment does not automatically mean hearing impairment. Speaking clearly, at a normal volume and pace, and facing the client is preferred. Yelling can be perceived as rude or patronizing and may not help comprehension. If hearing loss is present, use appropriate hearing accommodations instead.

Use gestures to communicate with the client: Gestures rely on vision and are less helpful for someone with moderate visual impairment. Instead, use clear verbal descriptions, tactile cues when appropriate (with permission), and accessible written material (large print, audio) to reinforce teaching.

Dilation of pupils: Pupillary dilation is a sympathetic response seen in the alarm (and to some extent resistance) stage when the body is mobilizing to cope. In the exhaustion stage, compensatory mechanisms fail and acute sympathetic signs are less prominent.

Blood pressure increases: Elevated blood pressure is typical during the alarm/resistance stages due to sustained sympathetic activity and cortisol. In the exhaustion stage, physiologic resources are depleted and blood pressure may fall or the person becomes more vulnerable to illness and collapse.

Blood glucose levels return to the expected reference range: During prolonged stress (resistance stage), cortisol and catecholamines raise blood glucose. In exhaustion, metabolic dysregulation can continue or worsen rather than neatly return to normal-the body’s regulatory systems are strained, and glucose abnormalities may persist or decompensate rather than reliably normalize.

"Limit your calcium intake.": For most patients with calcium-containing stones, restricting dietary calcium is not routinely recommended because low dietary calcium can actually increase oxalate absorption and stone risk. Instead, dietary calcium should often be maintained at normal levels unless the client has a specific metabolic abnormality; individualized dietary counseling is necessary.

"Drink 1 liter of fluid each day.": This fluid amount is insufficient to prevent stones. Typical prevention advice is to aim for 2–3 liters of fluid daily (enough to produce ~2 to 2.5 L of urine/day) to reduce urinary saturation of stone-forming salts.

"Choose sugar-sweetened beverages.": Sugar-sweetened drinks (sodas, sweetened juices) are associated with increased stone risk and metabolic problems; they’re not recommended. Encourage water and, depending on stone type, other appropriate beverage choices (e.g., citrate-containing fluids for certain stones).

Irritable bowel syndrome (IBS): IBS is a functional gastrointestinal disorder that can be exacerbated by stress but is not defined by flashbacks of a traumatic event. It presents with abdominal pain and altered bowel habits, not re-experiencing symptoms.

Acute stress disorder (ASD): Acute stress disorder occurs within the first month after a traumatic event and lasts from 3 days to up to 1 month. Flashbacks occurring a year after the trauma do not meet the timing criteria for ASD.

Episodic acute stress: “Episodic acute stress” is not a formal diagnosis for trauma-related re-experiencing symptoms and would not explain persistent flashbacks occurring a year later. This choice is vague and does not align with diagnostic criteria.