SBAR Assessment of Older Adults

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 glasses of water each day and makes "sun tea" as a frequent beverage. 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 / self-concept: The patient seems to have a positive self-image, is proud of her family and of the fact that she can still take care of herself. She still chops firewood, preserves food, and sews.

Role relationship: She is interested in the activities of her grandchildren and great grandchildren. She organizes traditional dance lessons and helps plan cultural events. She would like to have more income, and hopes that some money from the government for restitution (this was in the paper) will help her and the tribe.

Sexual reproductive: The patient said in no uncertain terms that she had no interest in this area.

Coping-stress tolerance: The patients said that the most stressful things in her life have to do with the difficulties of the young people in the tribe. She worries about drugs, alcohol, and lack of opportunity. The patient said that she relieves her stress by working hard and talking to her daughters and at tribal council.

Value-belief pattern: Her religion is a strong support to her, and she says she gets along.

A

Assessment -- Vitals

Blood pressure -- 120 / 80

Pulse -- 86

Respiration -- 20

Temperature - 96.8 degrees

Breathing was clear, no murmurs detected, palpation did not reveal any masses or irregularities.

R

Recommendation