Description
please I need two SBAR and Two Concept map for two patient
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I-SBAR
Your Name:
D#:
I – Introduce Yourself
Your Title:
Reason for being there:
Patient:
Attending Physician:
Age:
Patient Chief Complaint/Primary Medical Diagnosis
and Clinical Significance:
Gender/Identity:
Height/Weight:
Allergies:
S – Situation
Code Status:
Advance Directive (durable power of attorney,
living will, other) and Clinical Significance:
Pathophysiology of Primary Medical Diagnosis:
Privacy Code:
Date of Care/Time:
Include clinical significance with each:
Past Medical History:
B – Background
Past Surgical History:
Immunizations Received:
Social History/Socioeconomic Factors:
Vital Signs:
B/P
HR
RR
TEMP
SP02
A – Assessment
Fall Risk:
Accu-check:
IV Site:
IV Fluids:
Lab/Test Results:
I and O
Isolation
Isolation Precautions: Y ☐
N☐
Contact Air ☐
RESPIRATORY
CARDIOVASCULAR
NEUROLOGICAL
GI/GU
INTEGUMENTARY
PSYCHOLOGICAL FAMILY –
SUPPORT
Teaching needed:
SAFETY
Quality in Safety Education Nurses (QSEN) Risk(s) Identified:
Hand off report to:
R – REQUEST/ RECOMMENDATION
From:
Droplet ☐
PAIN
CONCEPT MAP
Student Name:
Date: PP
Priority (Top 3) Interventions,
Priority (Top 3) Information/Findings/
Signs and Symptoms (Cues)
Priority (Top 3) Lab
Values/Diagnostic Results
Related to Nursing Diagnosis
Potential and Actual Complications
(Include dietary risk factors)
Nursing Diagnosis
Priority (Top 3) Contributing
Social Determinants of Health
(SDOH)/ Healthcare
Disparities Factors
Priority (Top 3) Patient Outcomes
Priority (Top 3) Medication(s)
and Patient Teaching r/t Diagnosis.
Identify how the Four Spheres of
Care (AACN, 2019) were addressed
while caring for your patient. *
Priority (Top 3) Discharge Instructions and Evaluation of Effectiveness of Teaching
* If a sphere is not applicable, provide rationale and/or exploration of how this could be incorporated into care.
1. Wellness and Disease Prevention (includes physical and mental health needs).
2. Chronic Disease Management (includes managing chronic disease and preventing further complications).
3. Regenerative/Restorative Care (includes complex acute, trauma, and critical care and acute exacerbations of chronic conditions).
4. Hospice/Palliative Care (includes end-of-life care and supportive care for complex diseases and/or rehabilitative care).
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