Jordan SBAR Fillable PDF PDF

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SBAR Template Situation: Jordan Thompson is an 18-year-old African-American transgender male with a history of major depressive disorder BRIEF summary of primary problem:(MDD) and suicidal ideation and self-harm behaviors. He recently attempted to harm himself with repeated cuts into his left inner thigh using a metal tack. Client reports suicidal ideation. Day of admission/post-op #: Name/age:

Background: Primary problem/diagnosis:

Client has suicidal ideation after self-harming. Client has a history of MDD, suicidal ideation, and self-harm behaviors. He has

RELEVANT past medical history: multiple scars from previous self-harm. RELEVANT background data:

Client was assigned female at birth and identified as transgender male since age 14. Client's mother died of drug overdose when he was an infant and has no family support system, he is a ward of the state and his county social worker is his closest support person.

Assessment: Current vital signs:

Client's current vital signs are normal, with T of 98.5F, Pulse 88, RR of 16, BP of 128/82, and 99% O2 Sats on room air.

RELEVANT body system Mental status examiniation showed a sad mood with frustration and an anxiety level of nursing assessment data: 6/10. Client is preoccupied with gender affirming surgery. Insight and judgement is

somewhat limited and describes self-destructive behavior as impulsive. Impulse control is limited what acutely upset. Patient has suicidal ideation but denies having a plan.

RELEVANT lab values:

No labs were reported.

TREND of any abnormal clinical data (stableincreasing/decreasing):

Increase in anxiety and lack of impulse control show a decreasing mental status but seemingly improving upon admission.

How have you advanced theWe have implemented suicide precautions with a 1:1 sitter and have an order for Lorazepam as needed every 2-4 hours. We plan to continue to assess for risk of self-harm plan of care? and anxiety control.

Patient response:

Patient seems to be doing well with care given so far and is improving. Patient will report an decreased anxiety level.

INTERPRETATION of

Care is working as client is becoming more stable.

current clinical status (stable/unstable/worsening):

Recommendation: Suggestions to advance plan of care:I recommend continuing mental health assessments, as well as continued suicide precautions. I also recommend that patient be assessed for support system and educated about support systems he can reach out to.

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