Filli in the ISBAR Communication Worksheet with the flooring…

Question Answered step-by-step Filli in the ISBAR Communication Worksheet with the flooring… Filli in the ISBAR Communication Worksheet with the flooring information.  Medical Diagnosis: Intestinal ObstructionB.T. is a 30 year old male with a history of abdominal surgery 2 weeks ago for appendicitis. B.T. works in computer industry and is single. No other pertinent medical history. Non-smoker.Nursing Assessment:B.T. states, “My stomach started hurting really bad, and since I had surgery recently, I knew something was wrong.” Heart rate (HR) 98 regular. Blood pressure (Bp) 110/90. Temp 100.4 F orally. Capillary refill greater than 3 seconds in all extremities. Respiratory rate (RR) 18 breaths per minute. Oxygen saturation (O2 sat) 96%. Holding abdomen and friend brought B.T. to the emergency department. States pain level 9/10, sharp with movement in abdomen and standing, and is “just sort of there all the time.” Abdomen distended and firm on palpation. Bowel sounds diminished in all quadrants. Pain started “sometime yesterday.” States last bowel movement 2 days ago, firm, brown, and no difficulty defecating. Urine sample dark straw color 50 mL. Skin color normal for ethnicity, pale, dry. Mucous membranes dry and pale. States having nausea for the last day and “threw up once this morning.” Oriented to person, place, time, and situation. Grimacing on face.Nursing Diagnosis: 1.Dysfunctional Gastrointestinal motility related to sedentary lifestyle of immobility as evidenced by client stating ast bowel movement 2 days ago, firm, brown, and no difficulty defecating. States having nausea for the last day and “threw up once this morning.” Abdomen distended and firm on palpation. Bowel sounds diminished in all quadrants. Urine sample dark straw color 50 mL2.Risk for imbalanced temperature risk factors Temp: 100.4, BP: 110/90, Capillary refill greater than 3 seconds in all extremities.3. Delayed surgical recovery as evidenced by HR 98 regular, BP 110/90, Capillary refill greater than 3 seconds in all extremities. ,Holding abdomen.The nursing assessment above took place on the due date at 1140.Additional Information for the documentation:The nurse calls the physician at 1230 requesting labs and for the physician to see the client. After the physician assesses the patient and writes orders, the nurse initiates a peripheral IV in the right forearm IV site, administers antibiotics as ordered, an antipyretic as ordered, and begins an intravenous infusion (IV) of Lactated ringers at 125 mL/hr. At 1330 the client’s vital signs are HR 88, Bp 124/88, temp 99.0F, and oxygen saturation 99% on room air. The client states, “I’m feeling a bit better but tired.”  Introduction:Nurse’s Name: Ashley Davis___ Provider’s name; Dr._Saintil_______Unit: ___6A____Patient Initials: ___B.T__________ Patient Date of Birth: ___30_____ Room Number ___608____________ I – Hello, Dr. Saintil, this is Ashley the nurse on 6A caring for B.T in room 608.  Date: ___05.09.2021___ Time: ________________ Location: _______6A______________________________  Pre-call preparation: Gather the following information: Patient’s name; age; chart. Rehearse in your mind what you plan to say. Run it by another nurse if unsure. If calling about pain, when and what was last pain medication? If calling about fever, what was the most recent temperature? If calling about an abnormal lab, what was the result of the last test? What is the goal of your call? Remember to start by introducing yourself by name and location. Use area below as a checklist to gather your thoughts and prepare. Situation:  Briefly describe the current situation. Give a clear, succinct overview of pertinent issues :S- The situation is the client is    Background:  Briefly state the pertinent history. What got us to this point?:       Assessment:  Summarize the facts and give your best assessment. What is going on? Use your best judgement:     Recommendation: What actions are you asking for? What do you want to happen next?        Health Science Science Nursing NSG 110 Share QuestionEmailCopy link Comments (0)