Question

DAR, SBAR and Nursing Diagnosis scenario:

Mrs. Simson is a 83-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

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 ___Situation____________________________	83 year old female hospitalized today for dehydration and UTI. Recently she lost her husband and become agitated with the hospital environment.
B ___Background____________________________	History of Alzhemier's disease for past 12 years and had diabetes, HTN, osteoarthritis, and depression. Currently she is on several medication. She needs assist for walk and stand.
A __Assessment______________________________	The patient was assessed completely both physically and mentally. She was agitated and want to go to her home. Vitals are checked. Side rails placed. the alarm kept in place. floor mats are down and family members are present nearby. Patient activity is checked frequently.
R ___Request_____________________________	I would request the primary care provider to order for sedatives to control for agitation. The patient was frequently observed for the response.

3.Nursing Diagnosis:

Increased agitation or restlessness related to depression as evidenced by the agitative behavior.

4. Patient outcome/goal

The patient should return to appropriate normal behavior.

2. DAR Entry:

Date/time	Focus	Nursing Progress Notes	Initials
11/29/08	Safety
0830
		Data: Patient was agitated and getting out of bed and
		pulled IV lines three times.	Nurse RN
0850
		Action: Received written order of applying of bilateral hand covers continuously and lorazepam 0.5mg IV every 1 hour.	Nurse RN.
		Applied hand cover bilaterally and lorazepam infusion started.	Nurse RN
0930
		Response: Observed the patient. The patient is	Nurse RN.
		comfortable and sleeping. IV infusion is on flow.