What This Document Is
This is a standardized SBAR (Situation, Background, Assessment, Recommendation) form specifically designed for nursery clinical rotations within the Maternal Child Nursing (NRSG 112) course at Ivy Tech Community College of Indiana. It serves as a structured communication tool for nurses to concisely report on a newborn patient’s status and care plan. The form is pre-populated with sections for key newborn data and includes a concept map component focused on breastfeeding support.
Why This Document Matters
This SBAR template is essential for nursing students completing their clinical experience in a NICU or nursery setting. It ensures consistent, clear, and safe handoffs of patient information between nurses, promoting continuity of care. It’s used during shift changes, when consulting with other healthcare professionals, or when transferring a patient. The inclusion of a concept map section reinforces the application of nursing diagnoses and care planning skills.
Common Limitations or Challenges
This document is a *template* for communication. It requires the nurse to actively assess the patient and populate the fields with accurate, current information. It does not provide clinical decision-making guidance or replace the need for comprehensive nursing knowledge. It focuses on a single patient encounter and doesn’t represent a complete medical record.
What This Document Provides
The full document includes:
* A pre-formatted SBAR structure with sections for Situation, Background, Assessment, and Recommendation.
* Specific fields for documenting newborn gestational age, delivery details, weight, medications, and reason for NICU admission (if applicable).
* A dedicated section for detailing feeding information (breastfeeding, bottle, NG/OG feeds).
* Newborn assessment findings, including vital signs, physical exam details, and screening results.
* A concept map framework with sections for identifying nursing diagnoses, expected outcomes, and interventions related to patient care – specifically, a case study focused on breastfeeding challenges.
* A list of medications administered, including route, frequency, rationale, common side effects, and parent teaching points.
* A skills checklist for documenting procedures performed during the shift.
This preview does *not* include completed examples, detailed assessment findings, or the full content of the referenced breastfeeding resource. It is a structural overview of the SBAR form itself.
