Mrs. Hope is an 86 year-old widowed

Mrs. Hope is an 86 year-old widowed female who was admitted to a nursing home 3 months ago. She is ambulatory, and able to perform self-care but transitioned to the nursing home after several falls in her apartment, with the latest one resulting in a fractured hip. Mrs. Hope does require the use of a walker since her surgical procedure. Her past medical history includes osteoarthritis, type II diabetes mellitus, hypercholesterolemia, and hypertension. She has three daughters and 7 grandchildren that visit on a regular basis. Today, Mrs. Hope’s daughter approaches you and states “I have some concerns about my mom. She doesn’t seem to have a lot of energy, and she is falling asleep during our conversations. I am very concerned about this change.” During your shift yesterday, you noted that Mrs. Hope did not each much of her dinner (only 25%) and she left the dining room early asking for her bedtime pills because she was very tired and wanted to go to bed. Given your observations, and the information provided by the daughter you make the decision to conduct a sleep assessment. During the sleep assessment Mrs. Hope provides the following information: she likes to go to bed around 8 pm, 9 at the latest she finds that she is able to fall asleep quickly, but wakes up several times during the night due to noise, having to urinate, and feeling cold (despite using multiple blankets) it takes hours for her to fall asleep after she has waken up she complains that her room is too bright, she likes to keep the bathroom light so she can easily locate it when she wakes up and needs to urinate Upon review of the chart, you not that several PSWs and nurses have documented that Mrs. Hope falls asleep during her meals, struggles with maintaining a conversation, and frequently states “I am just so tired”. It is noted that Mrs. Hope does not take any medications to assist with sleep, but frequently has a coffee with her nighttime snack. She does not participate in group activities, due to low energy and fatigue. SBAR: report about a situation S Situation: This is____________________ I’m calling from____________________ (unit) I am calling about :___________________________________________________ (pt. name and location) The patient’s code status is:____________________________________________ The problem I am calling about is ____________________________. I have just assessed the patient personally: Vital signs are: Blood pressure _____/_____, Pulse ______, Respiration_____ ,temperature ______, O2 sat______ I am concerned about the: B Background: A Assessment:__This is what I think the problem is:_______________________________________ __The problem seems to be: __I am not sure what the problem is but the patient is deteriorating. __The patient seems to be unstable, we need to do something. __I’m afraid the patient may arrest R Recommendation I request that you_____________________________________________ __Come to see the patient at this time. __Talk to the patient or family about code status. Are any interventions required?: If a change in treatment is ordered then ask: __How often do you want vital signs? __How long to you expect this problem will last? __If the patient does not get better when would you want us to call again? SCIENCE HEALTH SCIENCE NURSING PNH 201

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