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SBAR Depression - Lecture notes 1

Depression
Course

Health Care Concepts (NSG 211)

8 Documents
Students shared 8 documents in this course
Academic year: 2019/2020
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Technische Universiteit Delft

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SBAR Template: Abigail Harris - Depression

S

Situation: Abigail Harris is an 86-year-old African American woman who come into the ER today with weakness and fatigue. She seems to have worsening depression, but there are several symptoms that overlap her hypothyroidism.

B

Background: Mrs. Harris has a history of diabetes and depression, with a recent history of nearly falling due to dizziness and unsteadiness. She has been taking her daytime insulin though she doesn't feel like eating. She has very poor energy and appetite.

A

Assessment: Mrs. Harris has a regular HR, clear breath sounds, head exam unremarkable except dry mucous membranes & lips. Blood glucose 66. Urine concentrated. Took morning thyroid medicine and insulin but reports little or no P. intake; did not take other "morning" P. medications Depression screen remarkable for moderate depressive symptoms: her PHQ 9 score is 16, positive for energy, sleep, appetite, concentration, interest, & slowed-down problems, and rates impairment as moderate. Fall risk high. She is continent of bladder and bowel. Blood chemistry and urinalysis consistent with mild dehydration.

R

Recommendation: Based on my assessment, the depression symptoms are contributing to difficulty in managing her other medical conditions, and she is at moderate risk for further complications of those conditions. Specifically, I recommend that her diabetes and fluid balance need to be stabilized. Continue to monitor blood glucose and P. intake and hold insulin if intake is not adequate; correct fluid balance; ambulate with assistance; toilet in advance of need every 2 hours, screen for falls risk; educate patient and family about intake and insulin; assess sleep quantity and quality; consult with physician for sliding scale for insulin.

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SBAR Depression - Lecture notes 1

Course: Health Care Concepts (NSG 211)

8 Documents
Students shared 8 documents in this course

University: University of Virginia

Was this document helpful?
SBAR Template: Abigail Harris - Depression
SSituation:
Abigail Harris is an 86-year-old African American woman who come
into the ER today with weakness and fatigue. She seems to have
worsening depression, but there are several symptoms that overlap
her hypothyroidism.
BBackground:
Mrs. Harris has a history of diabetes and depression, with a recent
history of nearly falling due to dizziness and unsteadiness. She has
been taking her daytime insulin though she doesn't feel like eating.
She has very poor energy and appetite.
AAssessment:
Mrs. Harris has a regular HR, clear breath sounds, head exam
unremarkable except dry mucous membranes & lips. Blood glucose 66.
Urine concentrated. Took morning thyroid medicine and insulin but
reports little or no P.O. intake; did not take other "morning" P.O.
medications Depression screen remarkable for moderate depressive
symptoms: her PHQ 9 score is 16, positive for energy, sleep, appetite,
concentration, interest, & slowed-down problems, and rates
impairment as moderate. Fall risk high. She is continent of bladder and
bowel. Blood chemistry and urinalysis consistent with mild
dehydration.
RRecommendation:
Based on my assessment, the depression symptoms are contributing
to difficulty in managing her other medical conditions, and she is at
moderate risk for further complications of those conditions.
Specifically, I recommend that her diabetes and fluid balance need to
be stabilized. Continue to monitor blood glucose and P.O. intake and
hold insulin if intake is not adequate; correct fluid balance; ambulate
with assistance; toilet in advance of need every 2 hours, screen for
falls risk; educate patient and family about intake and insulin; assess
sleep quantity and quality; consult with physician for sliding scale for
insulin.

Students also viewed

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