Question

The purpose of this assignment is to utilize standardized formats for reporting and documenting patient care activities.

Using the following data, write down how you would discuss the situation with the provider using the SBAR format. Next, document a focus note (DAR) using the correct documentation terms and abbreviations.

DAR, SBAR and Nursing Diagnosis scenario:

Mrs. Polly Walker is a 93 year old patient. She has had Alzheimer’s for 12 years and recently lost her husband. Her medical history includes diabetes, hypertension, osteoarthritis and depression. She takes several medications for her conditions. Recently she has worsening agitation and insomnia. At her long term care facility she walks with a walker and standby assist. She was admitted to the hospital (room 508) this morning for dehydration and is being treated for UTI. She was incontinent of urine x2 this morning. Vital signs: 99.6-64-18-99/60-96% on room air. White blood cell count (WBC) is 20.1. She states she wants to go home to the farm and has been calling out for her husband to help her “This place is too noisy, I need to get out of here!”. Bed alarm is in place, floor mats are down, room is close to the nurses’ station, 2 side rails are up, and a family member is present. Mrs. Polly Walker repeatedly attempts to get out of bed and has pulled her IV out 3 times and is due for her next dose of antibiotic.

1. SBAR. (4 points)

Fill in the blanks for each letter listed below in this column.

Using the data above, fill in this column with the information you would communicate to the provider, using the SBAR format.

S ________________________________

B ________________________________

A ________________________________

R ________________________________

You receive the following written orders from the primary care provider at 0850:

Apply bilateral hand covers (non-restraint) to be used continuously.
Lorazepam 0.5mg IV every 1 hour as needed for agitation.

You implement both interventions and patient was resting comfortably with IV antibiotic infusing at 0930.

2. Next, document a focus note (DAR) using the correct documentation terms and abbreviations. (3 points).

DAR Entry:

Date/time

Focus

Nursing Progress Notes

Initials

11/29/08

Safety

0830

0850

0930

3. Considering the scenario above, formulate a Nursing diagnosis statement pertinent to this patient (1 point):

4. Formulate a Patient Outcome/Goal that correlates with the Nursing Diagnosis for the patient in the scenario above (1 point):

Answer 1

1) SBAR: A) Situation: Mrs polly walker 93years and her chief complaint is dehydration,and recently she was havinginsomnia and worsening agitation. B) B-Background: she was admitted to the hospital in the morning, and she is having alzehmir for 12 years andshe lost her husband recently and she is having hypertension, diabetes , osteoarthritis and depression, and she is on medication for all her conditions and she is advised for long term care facility she is using walker and standby assist and her vital signs are 99.6-64-18-99/60-96% and wbc count is 20.1 and inconstient of urine.C)A-Assessment the patient is having worsening agitation and insomia, D)Recommendation: she is having urinary track infection and she due of next dose of antibiotics, 2)DAR: a format or method of identifying and organizing the narrative documentation of all client concerns and it consists of data , action, and response, dar entry : date/time is 11/29/08 focus is safety and at time 0830 she was admitted to the hospital(room 508) this morning for dehydration and is being treated for urinary tract infection, and at 0850 primary care provider is written and bilateral handcovers (non restraint) to be used continuosuly and lorazepan 0.5 mg IV every 1 hour as needed for agitation, and at 0930 the patient is given both intervention and patient was resting comfortably with IV antibitoic infusing. 3)Nursing diagnosis:insomia: disturbed sleep pattern related to sensory changes and urinary infecion and incompetency related to neurological function loss, 4) The patient goal icnludes the patients safety . independences in self care activities , and reducing anxiety and agitation etc.