Health Assessment of a 75-Year-Old Navajo Woman: SBAR Report
This paper presents a clinical health assessment of a 75-year-old Navajo woman living on a reservation, using the SBAR (Situation-Background-Assessment-Recommendation) communication framework originally developed by Kaiser Permanente. The assessment covers the patient's physical examination across multiple functional domains — including nutrition, elimination, activity, cognition, psychosocial well-being, and coping — alongside her vital signs and clinical findings. Based on the assessment, the paper outlines targeted recommendations addressing joint pain from arthritis, hydration, urinary health, hearing, and preventive screening. The case illustrates the application of SBAR in a culturally sensitive geriatric context.
- Overview of the SBAR Framework: Introduction to the SBAR communication tool
- Situation and Patient Background: Patient demographics and presenting complaint
- Physical Examination Findings: Multi-domain physical and psychosocial exam
- Vital Signs and Clinical Assessment: Objective vital signs and clinical findings
- Recommendations and Care Plan: Dietary, preventive, and assistive care recommendations
- Conclusion: Summary of health status and care outlook
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What makes this paper effective
- Follows a recognized clinical communication structure (SBAR), giving the assessment immediate professional credibility and organizational clarity.
- Integrates cultural context — the patient's tribal community, traditional practices, and economic circumstances — into the clinical picture without oversimplifying it.
- Balances objective data (vitals, lab findings) with subjective patient reporting across multiple functional health domains, producing a holistic geriatric profile.
Key academic technique demonstrated
The paper demonstrates systematic use of a standardized clinical framework (SBAR) to organize patient data from subjective history-taking through objective examination to actionable recommendations. This technique shows how structured communication tools can be adapted beyond their original patient handoff context to support comprehensive health reporting.
Structure breakdown
The paper opens with a brief explanation of the SBAR tool and its source, then moves through the four SBAR components in order: Situation (patient demographics and chief complaint), Background (multi-domain physical examination), Assessment (vital signs and clinical findings), and Recommendation (individualized care guidance). The structure is clinical and sequential, with each section building on the previous one to support the final care plan.
Overview of the SBAR Framework
The SBAR (Situation-Background-Assessment-Recommendation) technique provides a framework for communication between members of the healthcare team. Although this technique was originally developed to target patient-centered clinical handoffs, it can be implemented to communicate and address critical issues requiring immediate attention and action. This SBAR tool was developed by Kaiser Permanente.
Situation and Patient Background
The patient is a 75-year-old Navajo woman who lives with her family on the reservation. She has never been hospitalized, has not had any major or minor surgery, and does receive annual check-ups and immunizations. She presents today with complaints of joint pain in her hands that is keeping her from working on the handicrafts she makes to supplement her income.
Physical Examination Findings
The patient does not take any supplements and reports that she does not consume much meat, other than lamb during the season and chicken year-round. Her salt consumption is low and she does not eat many packaged snacks. She drinks about six glasses of water each day and frequently makes "sun tea" as a beverage. The patient has remarkably retained most of her own teeth and says that chewing is not difficult, though swallowing sometimes causes her problems. She reports that her skin feels dry.
The patient reports no difficulty with bowel elimination. She believes her diet and regular morning and evening walks help keep her regular. Lately, she reports some issues with bladder control but does not experience pain or discomfort. Lab reports show a very low white blood cell count in the urine and no infection.
The patient maintains a small garden and helps tend sheep and chickens. She shops in town about twice each month and reports no trouble getting around, other than occasional stiffness.
The patient has worn glasses since she turned 40. She reports that her hearing is less acute than when she was younger, but that she manages. She has considered getting a hearing aid. The patient reads the tribal newspaper and was able to name several recent news events she had watched on television.
The patient appears to have a positive self-image and is proud of her family and of her continued ability to care for herself. She still chops firewood, preserves food, and sews.
She is actively interested in the lives of her grandchildren and great-grandchildren. She organizes traditional dance lessons and helps plan cultural events for the tribe. She would like to have more income and hopes that government restitution funds she read about in the paper will benefit her and the tribe.
The patient stated clearly that she had no interest in this area.
The patient identified the difficulties facing young people in the tribe as her primary source of stress, including concerns about drug and alcohol use and lack of opportunity. She manages stress by working hard and by talking with her daughters and participating in tribal council meetings.
Her religion is a strong source of support in her life, and she reports that she gets along well overall.
Conclusion
This SBAR assessment demonstrates the value of structured, culturally informed clinical communication for older adult patients. The patient's overall health is notably strong for her age, and her active engagement with the care team — including her willingness to pursue preventive screenings, consider assistive devices, and adjust her diet — suggests good prospects for follow-through on the recommended interventions. Continued support that respects her cultural values and community context will be important to her ongoing well-being.
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