You are a nurse working the night shift. At 06:45, you are preparing to give a handoff report to the day shift nurse for Mr. Robert Sanchez, a 55-year-old patient admitted with new-onset chest pain. During the night, Mr. Sanchez reported his pain had increased from a 2/10 to a 7/10 at 04:00, accompanied by diaphoresis and shortness of breath. You administered prescribed sublingual nitroglycerin, and his pain decreased to 3/10. His vital signs at 04:15 were BP 100/60, HR 110, RR 24, O2 Sat 92% on room air. He was then placed on 2L nasal cannula, and O2 sat improved to 96%. You documented these events in the electronic health record (EHR). Discussion Questions: 1. When documenting Mr. Sanchez’s episode in the EHR, what are three essential principles of documentation you must adhere to, and why are they important? 2. Using the SBAR format, what key information would you include in your handoff report to the day shift nurse regarding Mr. Sanchez’s chest pain episode? 3. During your handoff, the day shift nurse asks, “Why do you think his pain increased so suddenly?” How should you respond, adhering to principles of professional communication?
[Answered]: You are a nurse working the night shift
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