Health Assessment -- Older Adult
SBAR TEMPLATE
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the health care team. Although this technique was original developed to target a patient-centered condition, the NNLC will implement this technique to communicate and address critical issues to support immediate attention and action by the committee. This SBAR tool was developed by Kaiser Permanente.
Situation:
The patient is a 75-year-old Navaho woman who lives with her family on the reservation. She has not ever been hospitalized, has not had any major or minor surgery, and does get annual check-ups and immunizations. She presents today with complaints of joint pains in her hands that are keeping her from working on the handicrafts that she makes to supplement her income.
B
Physical Exam
Nutritional / Metabolic: The patient does not take any supplements and reports that she does not consume much meat, other than lamb during the season and chicken all year long. Her salt consumption is low and she does not eat many packages snacks. She drinks about six...
The patient has remarkably retained most of her own teeth, and says that chewing is not difficult, but swallowing sometimes gives her problems. She reports that her skin feels dry.
Elimination: The patient reports that she does not have difficulty with bowl elimination. She believes her diet and her regular walking about in the morning and evening help keep her regular. Lately, she reports that she has some issues with bladder control, but does not experience pain or discomfort. (Lab reports show very low white blood count in the urine and no infection.)
Activity exercise: The patient maintains a small garden and helps to tends sheep and chickens. She shops in town about twice each month, and says she has no trouble getting around, other than occasional stiffness.
Cognitive-perceptual: The patient has worn glasses since she turned 40. She reports that her hearing is less acute than when she was younger, but that she gets by. She has thought about getting a hearing aid. The patient reads the nation's paper and could name several events that she had watched on the news.
Self-perception…
