SBAR Depression - Lecture notes 1 PDF

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Depression...

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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.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.

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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.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....