For each entry below, choose the component of SBAR that it most accurately represents.
Documentation entry: "The patient has a fractured right tibia with a cast that was applied 2 days ago.
The nurse requests that the primary health provider examine the patient.
The patient reported his pain as a 7 on a 0-10 pain scale 1 hour after he received Norco 10mg PO. The patient's toes are cool and pale, and the patient reports that the foot feels numb.”.

Choice A rationale

The physician is responsible for medical diagnoses, which identify diseases or medical conditions based on the patient's signs, symptoms, and diagnostic test results. While nurses use medical diagnoses to inform their care, they do not analyze data to arrive at them.

Choice B rationale

The patient provides subjective data about their health status, which is crucial information for the nurse's assessment. However, the patient does not have the clinical knowledge and expertise to analyze and interpret this data in the context of other findings to formulate a nursing diagnosis.

Choice C rationale

The nurse is responsible for collecting, analyzing, and interpreting patient data (both subjective and objective) to identify patterns, draw conclusions about the patient's health status, and formulate nursing diagnoses. Nursing diagnoses describe the patient's responses to actual or potential health problems that nurses are qualified and licensed to treat.

Choice D rationale

Therapists, such as physical therapists, occupational therapists, or respiratory therapists, focus on specific aspects of the patient's rehabilitation and treatment based on their area of expertise. While they contribute valuable data to the patient's overall care, they are not primarily responsible for formulating nursing diagnoses.

Choice A rationale

Setting priorities involves deciding the order in which nursing interventions should be implemented based on the urgency and importance of the client's needs. While addressing pain is often a high priority, the term itself doesn't specifically describe the cognitive process of interpreting nonverbal cues as pain.

Choice B rationale

Recognizing inconsistencies involves identifying discrepancies between verbal and nonverbal cues, or between the client's stated condition and observed behaviors. While the nurse is observing nonverbal cues, the primary action here is interpreting those cues, not necessarily identifying inconsistencies.

Choice C rationale

Making inferences involves interpreting cues and drawing conclusions based on available data. The nurse observes the client's moaning, clenched hands and teeth, and diaphoresis, and infers that these signs indicate the presence of pain. This interpretation then guides the decision to administer an analgesic.

Choice D rationale

Using empathy involves understanding and sharing the feelings of another person. While empathy is important in nursing care and may contribute to the nurse's interpretation of the client's distress, the specific cognitive process of interpreting the nonverbal cues as pain is termed making inferences.