NUR 665 SBAR Patient Encounter Form

Nursing Clinical Experience Date ___________
Total nursing clinical hours completed to date
Description of observations and tasks during the nursing clinical experience	During this clinical shift in the dialysis unit, I helped take care of several people who were getting hemodialysis. I watched as the dialysis machines were set up and primed. I also checked the patients’ identities and entry sites and took their vital signs before and after treatment. I also helped evaluate a patient who had hyperkalemia before starting dialysis and kept an eye on their ECG results while they were on treatment (Morales et al., 2021). I also helped teach patients about potassium-restricted meals and how to control their fluid intake. These tasks helped me learn how important it is for nurses to keep patients stable and make sure they follow the rules for dialysis treatment.
Learner reflection on nursing clinical experience	This experience helped me learn more about how to handle dialysis and what the nurse’s role is in avoiding and treating problems like hyperkalemia. I learned how important it is to do thorough tests before dialysis, review lab results, and teach patients. The comprehensive aspect of renal treatment was highlighted by seeing the multidisciplinary cooperation between nephrologists, nutritionists, and nurses. Using the SBAR framework, I also got better at quickly sharing clinical results, which ensured patient safety and continuity of care. The experience helped me think differently, reinforced nursing practices based on research, and gave me more faith in my ability to care for people with end-stage kidney disease who are on regular dialysis.

SBAR
Situation: The exact circumstances of the situation are explained.	Ms. R., a 58-year-old woman with diabetic nephropathy-related end-stage renal disease (ESRD), arrived at the renal unit for her planned hemodialysis session. Laboratory findings from her pre-dialysis examination showed that her blood potassium level was dangerously increased at 6.1 mEq/L. In addition to minor palpitations and a tingling sensation in her hands, she described feeling weak. Her blood pressure was 162/92 mmHg, her pulse rate was 104 bpm, her respiration rate was 20 breaths per minute, and her oxygen saturation level on room air was 96%. The ECG showed elevated T waves, which are indicative of cardiac abnormalities brought on by hyperkalemia that require quick medical attention (Stambolliu et al., 2025).
Background: Presents essential information related to the situation. This information should pertain only to the current patient situation.	Due to her long-standing hypertension and poorly managed type 2 diabetes mellitus, Ms. R. has needed hemodialysis three times a week for the last two years due to ESRD. She is administered erythropoietin injections, insulin glargine, sevelamer for phosphate binding, and 10 mg of lisinopril each day. Although she is on a renal diet, she was recently committed for dietary noncompliance after spending the weekend eating items rich in potassium, such as potatoes and bananas. She has not skipped any recent dialysis treatments and does not have any known medication allergies. Her vascular access is a right upper-arm arteriovenous fistula, and examination and palpation revealed no indications of infection or access dysfunction (Fishbane et al., 2021).
Assessment: Objective statements based on the situation and background information.	The patient’s pre-dialysis laboratory values and electrocardiogram data reveal substantial hyperkalemia, an electrolyte imbalance that may pose a life-threatening risk. Her erratic heart rate, elevated T waves, and muscular weakness indicate that high serum potassium has already started to disrupt cardiac conduction. A physical exam showed no signs of severe respiratory distress, and her mental condition was awake and focused. The high potassium level is probably caused by eating too much and not being able to get rid of it via the kidneys. Dialysis is needed right away to fix hyperkalemia and stop arrhythmias. To make sure that fluid and electrolyte levels are safe throughout therapy, it is important to keep an eye on the patient’s vital signs, ECG, and work closely with the nephrologist (Hassaballa et al., 2022).
Recommendation: Include a recommendation for resolving the issue based on the situation, background, and assessment.	Do urgent hemodialysis right away to get rid of extra potassium and stabilize the patient’s heart rhythm. Maintain continuous ECG and vital sign monitoring during the session to identify any heart problems immediately (Fishbane et al., 2021). After dialysis, further blood tests should be done to check for rebound hyperkalemia and see whether the potassium levels have gone down. Reinforce dietary instruction by concentrating on foods that are low in potassium and how sticking to her prescription might affect her health. Work with the dietician to create a food plan that is culturally relevant and helps people stick to it. Also, suggest that the nephrologist check the patient’s drug regimen to see if any antihypertensives lower the risk of hyperkalemia (Stambolliu et al., 2025). This will make sure that the patient is getting continuing care from a team of experts.
Educational Plan: Include a suggestion for an educational plan to address one aspect of the patient’s care. Include recommendations based on evidence-based guidelines/research related to a specific patient finding.	Give the patient individualized instruction on how to prevent hyperkalemia, with an emphasis on recognizing and avoiding meals rich in potassium, following dialysis regimens, and recognizing the early signs of excessive potassium, such as palpitations, numbness, or muscular weakness (Fishbane et al., 2021). To guarantee understanding, use printed visual aids and teach-back techniques. To improve adherence, work with the nutritionist to continue nutritional counseling and include family members in the teaching process. Stress the value of regular lab testing, medication reviews, and follow-up visits. In order to maintain optimum electrolyte balance in dialysis patients, educational efforts should be in accordance with KDIGO (Kidney Disease: Improving Global Outcomes) and KDOQI (Kidney Disease Outcomes Quality Initiative) guidelines, which place a strong focus on patient involvement, self-management, and evidence-based therapies (Morales et al., 2021).

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References

Fishbane, S., Charytan, D. M., Chertow, G. M., Ford, M., Kovesdy, C. P., Pergola, P. E., Pollock, C., & Spinowitz, B. (2021). Consensus-Based recommendations for the management of hyperkalemia in the hemodialysis setting. Journal of Renal Nutrition, 32(4), e1–e14. https://doi.org/10.1053/j.jrn.2021.06.003

Hassaballa, M., El-Wakil, H., Elsharkawy, M., Khamis, S., Tantawy, T. E., Wahby, W., Salem, K., & Gawad, M. (2022). Egyptian renal data system (ERDS) 2020: an annual report of end-stage kidney disease patients on regular hemodialysis. Journal of the Egyptian Society of Nephrology and Transplantation, 22(1), 1. https://doi.org/10.4103/jesnt.jesnt_37_21

Morales, E., Cravedi, P., & Manrique, J. (2021). Management of chronic hyperkalemia in patients with chronic kidney disease: an old problem with new options. Frontiers in Medicine, 8. https://doi.org/10.3389/fmed.2021.653634

Stambolliu, E., Iliakis, P., Tsioufis, K., & Damianaki, A. (2025). Managing Hypertension in Chronic kidney Disease: The role of diet and guideline recommendations. Journal of Clinical Medicine, 14(11), 3755. https://doi.org/10.3390/jcm14113755

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Assessment Description

The purpose of this assignment is to complete the SBAR related to a patient you have assessed, to document your completed nursing clinical hours, and to self-reflect on your experiences with patients from a clinical nursing perspective.

Complete the “SBAR Patient Encounter Form,” located in Class Resources.

Submit the completed “SBAR Patient Encounter Form” to the assignment dropbox.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

APA style is not required, but solid academic writing?is expected.

You are not required to submit this assignment to LopesWrite.

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SBAR Patient Encounter Form – Submission 2 – Rubric

Rubric Criteria

Total10 points

Criterion	1. Unsatisfactory	2. Insufficient	3. Approaching	4. Acceptable	5. Target
Total Nursing Clinical Hours Completed Criteria Description	0 points The total nursing clinical hours completed are not reported accurately or are not presented.	1.3 points N/A	1.5 points N/A	1.7 points N/A	2 points The total nursing clinical hours completed are reported accurately.
Observations and Tasks	0 points A description of the observations and tasks performed during the clinical experience is not provided.	0.65 points A description of the observations and tasks performed during the clinical experience is incomplete or incorrect.	0.75 points A description of the observations and tasks performed during the clinical experience is included but lacks relevant supporting detail.	0.85 points A description of the observations and tasks performed during the clinical experience is complete and provides relevant supporting detail.	1 points A description of the observations and tasks performed during the clinical experience is thorough and includes substantial supporting details.
Reflection	0 points A personal reflection on the clinical experience is not included.	0.65 points A personal reflection on the clinical experience is included but lacks detail or is incomplete.	0.75 points A personal reflection on the clinical experience is present.	0.85 points A personal reflection on the clinical experience is detailed.	1 points A personal reflection on the clinical experience is thorough.
Situation	0 points The presentation of the problem and current patient situation is not included.	0.65 points The presentation of the problem and current patient situation lacks significant and necessary details.	0.75 points The presentation of the problem and current patient situation is referenced generally.	0.85 points The report presents a mostly correct overview of the problem and current patient situation.	1 points The report articulately provides a clear, concise statement of the problem and current patient situation.
Background	0 points Background information is not provided. Information is not accessible if requested by the receiver.	0.65 points Background information is incomplete or inaccurate. Information is accessible if requested by the receiver but is missing details.	0.75 points Background information is provided but lacks details. Some information is accessible if requested by the receiver.	0.85 points Background information is mostly provided. Information is mostly accessible if requested by the receiver.	1 points Background information is thoroughly developed with supporting details. Information is accessible if requested by the receiver.
Assessment	0 points Current assessment and urgency of the situation are not communicated. Information, if requested, is not accessible.	0.65 points Communication of current assessment is missing key elements and lacks necessary detail. Information, if requested, is not available.	0.75 points Communication of current assessment is lacking in some detail but effectively conveys urgency of client needs. Information, if requested by the receiver, is accessible.	0.85 points Learner correctly assesses current situation and communicates level of urgency. Information, if requested by the receiver, is accessible.	1 points Learner concisely conveys detailed assessment of the current situation and properly identifies if the problem is urgent or emergent.
Recommendation	0 points No recommendations are made.	0.65 points Recommendations are developed generally but lack key elements to make them complete. Requests for further interventions or recommendations are missing details.	0.75 points Recommendations are formulated generally, but rationale could be better developed. Requests for further interventions or recommendations lack specificity.	0.85 points Correct recommendations and rationales are made. General requests for further interventions are suggested.	1 points Learner clearly and concisely presents recommendations and rationales and communicates specific requests or suggestions for changes to the patient plan of care.
Educational Plan	0 points A suggestion for an educational plan to address one aspect of patient care is not included.	0.65 points A suggestion for an educational plan to address one aspect of patient care, with recommendations based on evidence-based guidelines/research related to a specific patient finding, is included but lacks details or is incomplete.	0.75 points A suggestion for an educational plan to address one aspect of patient care, with recommendations based on evidence-based guidelines/research related to a specific patient finding, is present.	0.85 points A suggestion for an educational plan to address one aspect of patient care, with recommendations based on evidence-based guidelines/research related to a specific patient finding, is detailed.	1 points A suggestion for an educational plan to address one aspect of patient care, with recommendations based on evidence-based guidelines/research related to a specific patient finding, is thorough.
Professionalism	0 points The report is characterized by inarticulate, unfocused, or rambling delivery; use of inaccurate or inappropriate clinical language; and lack of professional demeanor (inappropriate tone, apprehensive or overly confident delivery).	0.65 points The report is characterized by somewhat articulate delivery, occasional use of inappropriate clinical language, and somewhat professional demeanor (occasionally inappropriate tone or apprehensive delivery).	0.75 points The report is characterized by generally articulate and mostly appropriate clinical language. The report may have some areas of poorly focused delivery. The report has a generally professional demeanor (mostly appropriate tone, somewhat apprehensive delivery).	0.85 points The report uses mostly articulate, appropriate clinical language and demonstrates professional demeanor (appropriate tone, mostly confident delivery).	1 points The report uses clear, articulate, appropriate clinical language, and demonstrates appropriate professional demeanor (appropriate tone, confident delivery).

Criterion

1. Unsatisfactory

2. Insufficient

3. Approaching

4. Acceptable

5. Target

Total Nursing Clinical Hours Completed

Criteria Description

0 points

The total nursing clinical hours completed are not reported accurately or are not presented.

1.3 points

N/A

1.5 points

N/A

1.7 points

N/A

2 points

The total nursing clinical hours completed are reported accurately.

Observations and Tasks

0 points

A description of the observations and tasks performed during the clinical experience is not provided.

0.65 points

A description of the observations and tasks performed during the clinical experience is incomplete or incorrect.

0.75 points

A description of the observations and tasks performed during the clinical experience is included but lacks relevant supporting detail.

0.85 points

A description of the observations and tasks performed during the clinical experience is complete and provides relevant supporting detail.

1 points

A description of the observations and tasks performed during the clinical experience is thorough and includes substantial supporting details.

Reflection

0 points

A personal reflection on the clinical experience is not included.

0.65 points

A personal reflection on the clinical experience is included but lacks detail or is incomplete.

0.75 points

A personal reflection on the clinical experience is present.

0.85 points

A personal reflection on the clinical experience is detailed.

1 points

A personal reflection on the clinical experience is thorough.

Situation

0 points

The presentation of the problem and current patient situation is not included.

0.65 points

The presentation of the problem and current patient situation lacks significant and necessary details.

0.75 points

The presentation of the problem and current patient situation is referenced generally.

0.85 points

The report presents a mostly correct overview of the problem and current patient situation.

1 points

The report articulately provides a clear, concise statement of the problem and current patient situation.

Background

0 points

Background information is not provided. Information is not accessible if requested by the receiver.

0.65 points

Background information is incomplete or inaccurate. Information is accessible if requested by the receiver but is missing details.

0.75 points

Background information is provided but lacks details. Some information is accessible if requested by the receiver.

0.85 points

Background information is mostly provided. Information is mostly accessible if requested by the receiver.

1 points

Background information is thoroughly developed with supporting details. Information is accessible if requested by the receiver.

Assessment

0 points

Current assessment and urgency of the situation are not communicated. Information, if requested, is not accessible.

0.65 points

Communication of current assessment is missing key elements and lacks necessary detail. Information, if requested, is not available.

0.75 points

Communication of current assessment is lacking in some detail but effectively conveys urgency of client needs. Information, if requested by the receiver, is accessible.

0.85 points

Learner correctly assesses current situation and communicates level of urgency. Information, if requested by the receiver, is accessible.

1 points

Learner concisely conveys detailed assessment of the current situation and properly identifies if the problem is urgent or emergent.

Recommendation

0 points

No recommendations are made.

0.65 points

Recommendations are developed generally but lack key elements to make them complete. Requests for further interventions or recommendations are missing details.

0.75 points

Recommendations are formulated generally, but rationale could be better developed. Requests for further interventions or recommendations lack specificity.

0.85 points

Correct recommendations and rationales are made. General requests for further interventions are suggested.

1 points

Learner clearly and concisely presents recommendations and rationales and communicates specific requests or suggestions for changes to the patient plan of care.

Educational Plan

0 points

A suggestion for an educational plan to address one aspect of patient care is not included.

0.65 points

A suggestion for an educational plan to address one aspect of patient care, with recommendations based on evidence-based guidelines/research related to a specific patient finding, is included but lacks details or is incomplete.

0.75 points

A suggestion for an educational plan to address one aspect of patient care, with recommendations based on evidence-based guidelines/research related to a specific patient finding, is present.

0.85 points

A suggestion for an educational plan to address one aspect of patient care, with recommendations based on evidence-based guidelines/research related to a specific patient finding, is detailed.

1 points

A suggestion for an educational plan to address one aspect of patient care, with recommendations based on evidence-based guidelines/research related to a specific patient finding, is thorough.

Professionalism

0 points

The report is characterized by inarticulate, unfocused, or rambling delivery; use of inaccurate or inappropriate clinical language; and lack of professional demeanor (inappropriate tone, apprehensive or overly confident delivery).

0.65 points

The report is characterized by somewhat articulate delivery, occasional use of inappropriate clinical language, and somewhat professional demeanor (occasionally inappropriate tone or apprehensive delivery).

0.75 points

The report is characterized by generally articulate and mostly appropriate clinical language. The report may have some areas of poorly focused delivery. The report has a generally professional demeanor (mostly appropriate tone, somewhat apprehensive delivery).

0.85 points

The report uses mostly articulate, appropriate clinical language and demonstrates professional demeanor (appropriate tone, mostly confident delivery).

1 points

The report uses clear, articulate, appropriate clinical language, and demonstrates appropriate professional demeanor (appropriate tone, confident delivery).