SBAR -- don't know what to RECOMMEND

It depends. If your patient has deteriorating saturations, you might "recommend" (i.e. ask for) oxygen & lab orders. So you give the S-B-A, then say "So would you like me to start oxygen or get any labs?" Similarly, if your patient is febrile you could say "Do you want labs? Is isolation indicated? Can I have a tylenol order?"

With more experience, your conversations may go differently. "Doctor, I'm really concerned about such-and-such and do not feel comfortable giving NG feeds due to this symptom/issue. Can we make him NPO and up the IV fluids?"

Even after 8 years in my specialty area and familiarity and good working relationships with all my attendings, my conversations are usually more like the former. The latter is for unusual circumstances.

SBAR is a good thing, it really is. But, it's not necessary to use it all of the time. And, really, if you are calling the MD for something, that is your recommendation. For instance, "Hi, I'm calling about Mr ______. His HR is still 140, and I gave prn lopressor, dilaudid, etc, and he is resting comfortably. He had surgery 2 days ago for X. I already sent down a stat CBC to check for blood loss (that was your intervention and would have been your recommendation if you didn't do it yet), and then say, what more should we do?" (It depends on where you work, but in the ICU where I work, I feel that sending down lab work without an order, getting EKG's done, and Xrays done without the order first is actually best practice; waiting any period of time for the doc to call back could be detrimental since it takes a little while to process results anyway). I mean, really: if my patient is in obvious RD (that's not anxiety), a chest xray and an abg are in order. The physicians appreciate that we do what we can first prior to calling them. Never order any drugs without an order, though, obviously.

Sometimes, you really won't know what to do, and you'll just call, give them the quick update, and say, "I really don't know what more to to do for this person at this point." And, it's their job to come up with the answer.

But, just viewing your patient holistically, and making sure you look at the whole picture will certainly help you.

Your "recommendation" could be as simple as, "What would you like me to do for this patient in this situation?"

Basically, you're "recommending" that the physician does their "doctoring job" by giving orders for you to carry out.

If the patient has a high BP, you can ask/recommend that they prescribe something to bring down the blood pressure. You don't need to say, "I recommend prescribing 40mg of Lasix" -- you can just say "something for their blood pressure" and let the doc figure out what to prescribe and how much.

If the patient has consistently high blood glucose, you can ask/recommend that their sliding scale be adjusted -- and let the doc figure out what they want to adjust it to.

If the patient is complaining of pain, you can ask/recommend that something be prescribed for pain -- and let the doc figure out what drug and what dose.

The "R" in SBAR is just a way for you to give the doctor your "nurse's perspective" on things, because you're the one there who is laying eyeballs on the patient at that point in time. If your patient is complaining of 10/10 pain and wanting narcotics, but is chatting on her cell phone while filing her fingernails, you can "recommend" that the doctor prescribes 600mg of ibuprofen, based on what you're seeing happen with your patient.

Yes, it does come with experience. Say you have a 20 kg child, immediately post-op, ordered for morphine 1 mg q 4 hr PRN. The usual dosage for morphine is 0.05-0.1 mg/kg/dose q 2-4 hrs PRN. So this child is ordered for the lowest dose of the range. Say this ordered dose isn't holding them. My page to the doctor would be something like this "Pt Smith crying in pain 2 hrs after morphine, pls change order to q 2hr. thanks, KelRN." If the patient starts leaking CSF from their drain site or something, the page would say "come to room 2 now." Other situations warrant, "call now" and when they do call warrant a "this child needs a stat CT scan" or something of the sort.

The hospital I worked at for 5 years thought it invented SBAR. (It didn't.) We never really used it in practice.