Question

you are the nurse working triage in the emergency department. this afternoon, a woman brings in her father, K.B., who is 74 years old. the daughter reports that over the past year she has noticed her father has progressively had problems with his mental capacity. these changes have developed gradually but seem to be getting worse. at times he is alert and at other times he seems disoriented, depressed, and tearful. He is forgetting things and doing things out of the ordinary, such as placing the milk in the cupboard and sugar in the refrigerator. K.B. reports that he has been having memory problems for the past year and at times has difficulty remembering the names of family members and friends. His neighbor found him down the street 2 days ago, and K.B. did not know where he was. this morning he thought it was nighttime and wondered what his daughter was doing at his house. He could not pour his own coffee, and he seems to be getting more agitated. a review of his past medical history is significant for hypercholesterolemia and coronary artery disease. He had a myocardial infarction 5 years ago. K.B.'s vital signs today are all within normal limits.

Create a SBAR end of shift report.

Answer 1

SBAR end of shift report.

SITUATION

Here is the situation: Mr.K.B is having memory problems and is not able to remember the names of his friends and family.

BACKGROUND

The supporting background information is Mr. K.B is having problems with mental capacity for 1 year. He has a past history of hypercholesterolemia and coronary artery disease. He also had a myocardial infarction 5 years ago.

ASSESSMENT

My assessment of the situation is that he may be having a post-MI depression and memory decline.

RECOMMENDATION

I recommend a cardiac rehabilitation program and increased activity level.