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📋 护理管理 · 第6课，共7课 · 6 min

SBAR、交接班以及何时逐级向上反映

SBAR, Handoffs and When to Climb the Chain of Command

📞 现在是0300。患者的病情正在恶化。住院医师说：“观察一下，如果情况变糟就打给我。”你认为情况已经变糟了。接下来两分钟内发生的事情是一道经典的考试题。

📞 It is 0300. The client is deteriorating. The resident says, 'Watch and call me if it gets worse.' You believe it is already worse. What happens in the next two minutes is a classic exam question.

💡 核心要点

SBAR 让通话条理清晰；复述确认医嘱；当第一个答复不安全时，指挥链是你倡导的方式。

SBAR organizes the call; read-back confirms the order; the chain of command is how you advocate when the first answer is unsafe.

🧠 为什么重要

SBAR 使紧急沟通条理清晰：现状（SITUATION，你是谁，患者是谁，现在发生了什么），背景（BACKGROUND，诊断、相关病史、近期变化），评估（ASSESSMENT，你的判断和生命体征），建议（RECOMMENDATION，你想要什么：一项医嘱、床旁评估、转科）。要复述口头医嘱和电话医嘱，并让医疗服务提供者确认。换班时的交接报告必须详尽且不受打扰，并包括待办任务、异常发现和需要观察的事项。当医疗服务提供者的回应让患者处于不安全状态时，要使用指挥链（CHAIN OF COMMAND）：先找护士长，然后找护理（全院）主管，然后找主治医师或科主任，并遵循机构政策。如果患者符合快速反应标准（例如急性低血压、心动过速、精神状态改变，或护士的严重担忧），应立即启动快速反应团队。你不需要医疗服务提供者的许可，你可以在通知护士长和医疗服务提供者的同时这样做。要如实记录时间、联系过的人以及他们的回应。倡导有时意味着成为那个不断打电话的人。

SBAR structures urgent communication: SITUATION (who you are, who the client is, what is happening now), BACKGROUND (diagnosis, relevant history, recent changes), ASSESSMENT (your interpretation and the vital signs), RECOMMENDATION (what you want: an order, an evaluation at the bedside, a transfer). Read back verbal and telephone orders and have the provider confirm. HANDOFF reports at shift change must be thorough and uninterrupted and include pending tasks, abnormal findings and what to watch. When a provider's response leaves a client unsafe, use the CHAIN OF COMMAND: the charge nurse, then the nursing (house) supervisor, then the attending or chief, following facility policy. If the client meets rapid response criteria (for example, acute hypotension, tachycardia, a change in mental status or the nurse's serious concern), activate the rapid response team immediately. You do not need the provider's permission, and you can do this alongside notifying the charge nurse and the provider. Document the times, the people contacted and their responses, factually. Advocacy sometimes means being the person who keeps calling.

🏥 真实场景

🧗 一位护士报告一位术后患者心率上升、血压下降。住院医师下达了液体冲击治疗的医嘱，并说一小时后再重新评估。三十分钟后，血压更低了。护士回拨电话，被告知等一等，然后她打给了护士长和主治外科医生。患者被送回手术室，发现有一根血管在出血。护士坚持逐级上报，而不是接受“等一等”，这让患者及时回到了手术室。护士记录的四次通话，包括时间、姓名和回应，清楚地显示了做了什么以及何时做的，这支持了护理的连续性，也保护了护士本人。

🧗 A nurse reports a post-op client's rising heart rate and falling blood pressure. The resident orders a fluid bolus and says to reassess in an hour. Thirty minutes later the pressure is lower. The nurse calls back, is told to wait, and then calls the charge nurse and the attending surgeon. The client returns to the operating room with a bleeding vessel. The nurse's persistence in escalating, rather than accepting 'wait,' got the client back to surgery in time. The nurse's documentation of four calls with times, names and responses shows exactly what was done and when, which supports continuity of care and protects the nurse.

📌 要点总结

  • 现状、背景、评估、建议Situation, Background, Assessment, Recommendation
  • 复述每一项口头或电话医嘱Read back every verbal or phone order
  • 回应不安全时：逐级向上反映，并记录每一步Unsafe response: go up the chain and document every step

📖 本课术语

SBAR: 情景、背景、评估、建议：向提供者报告患者问题的结构。

✅ 自我测试

在一次 SBAR 通话中，“我认为患者有内出血，可能正在休克”属于哪个部分？In an SBAR call, 'I think the client is bleeding internally and may be going into shock' belongs to which part?
  1. 现状Situation
  2. 背景Background
  3. 建议Recommendation
  4. 评估Assessment

答案: D · 评估

评估是护士对问题的判断。现状说明现在发生了什么，背景给出临床背景，建议说明你希望做什么。

Assessment is the nurse's interpretation of the problem. Situation states what is happening now, background gives the clinical context, and recommendation states what you want done.

一位医疗服务提供者通过电话下达了一项新药的医嘱。护士必须怎么做？A provider gives a telephone order for a new medication. What must the nurse do?
  1. 改为请药剂师确认Ask the pharmacist to confirm instead
  2. 等书面医嘱，不管有多紧急都先什么也不做Wait for the written order before doing anything, regardless of urgency
  3. 复述医嘱并获得确认，然后再执行Read the order back and obtain confirmation before carrying it out
  4. 把它记下来，然后给药Write it down and give the medication

答案: C · 复述医嘱并获得确认，然后再执行

复述和确认可以防止转录错误。然后电话医嘱必须按照政策签字。把它记下来就给药，跳过了复述这一步，这样听错的药物、剂量或给药途径就会未经纠正地到达患者身上。

Read-back and confirmation prevent transcription errors. Telephone orders must then be signed per policy. Writing it down and giving the medication skips the read-back, so a misheard drug, dose or route would reach the client uncorrected.

值班医疗服务提供者拒绝评估一位护士认为正在恶化的患者。护士接下来应该怎么做？The on-call provider refuses to evaluate a client the nurse believes is deteriorating. What should the nurse do next?
  1. 通知护士长，并逐级向上反映Notify the charge nurse and go up the chain of command
  2. 记录这次拒绝，然后等白天团队来Document the refusal and wait for the day team
  3. 打电话给患者的家属请他们干预Call the client's family to intervene
  4. 给一种护士认为会有帮助的药物Give a medication the nurse thinks will help

答案: A · 通知护士长，并逐级向上反映

为患者倡导需要通过指挥链逐级上报，并记录每一次联系。记录拒绝是必要的，但等白天团队会让一位正在恶化的患者几个小时得不到评估。

Client advocacy requires escalation through the chain of command, with documentation of each contact. Documenting the refusal is necessary, but waiting for the day team leaves a deteriorating client without evaluation for hours.

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