A nurse is receiving change-of-shift report using SBAR to the oncoming nurse or a client who has a traumatic brain injury. Which of the following information should the nurse include in the background segment of SBAR?
Explanation & Rationale
A. Intracranial pressure readings: ICP readings are current assessment data and belong in the Assessment segment of SBAR rather than the background. These values help the oncoming nurse interpret the client’s current status but are not part of historical or contextual information. B. Plan of care changes for upcoming shift: Changes in the plan of care are included in the Recommendation segment of SBAR. This informs the oncoming nurse of anticipated actions but is not part of the client’s background history. C. Code status: Code status is typically included in the Situation segment, as it is critical for immediate decision-making during emergencies, not background context. D. Glasgow score: The Glasgow Coma Scale score provides a summary of the client’s neurological status prior to or at the time of the shift report and reflects baseline information relevant to the client’s condition. Including it in the Background segment gives context for current changes and ongoing care.