Assignment Isbar Week5 PDF

Preview

Summary

ISBAR Assignment/ Health Assessment...

Description

ISBAR Assignment Template – Health Assessment Student Name: Leonela Strataj. Circle the Course Week: W 5

W7

W 10

At times the right action for the nurse is to communicate their concerns about a patient’s clinical status. It is important to be confident and skilled in communicating with members of the health care team so they can signal the need for immediate action and support when required. “Good clinical communication is important in clinical reasoning and decision-making”. ISBAR is an effective way of communicating during phone calls and increasing patient safety (Mikos, 2007). Using ISBAR, write how you will communicate with the patient’s primary health care provider/physician over the phone? I

Identify

Self – name , position, location Patient – name, age, gender

S

Situation

Explain what has happened to trigger this phone call conversation

Hi Dr. A. It’s Leonela from X hospital. I’m calling to report for patient Mrs. F that I’m taking care of; 79 y old, female. Mrs.F was admitted 2 days ago with MVA. The problem I’m calling about is that Mrs. F felt tonight in bathroom. I am afraid that she hit her head and need a neuro consult. P 110 irregular R14 shallow Pulse ox 92% BP 90/70 lower than her usual 130/80 I am concerned about her decreased O2 sat, slow respond to verbal stimuli and BP.

B

Background

Admission date, diagnosis, relevant history, investigations, what has been done so far

79 y old, female involved MVA. Admitted 2 days ago R arm fracture in cast. CMS- WNL Diet- DAD LBM- 1 day ago Diphenhydramine 25mg q6 Vicodin with pain relief prn 0100-Awake, oriented x3, skin warm and dry. P 88slightly irregulated. Lung sound diminished bilaterally lower bases. Prn given. Diphenhydramine 25mg given.

0130- asleep 0430-Felt in bathroom VS- WNL Slightly noose bleeding Iced pack given Discharged this AM A

Assessment

Give a summary of the patient’s condition or situation. Explain what you think the problem is (if you can)

07-30 Slow to respond to verbal stimuli Lethargic Skin is cool Slight cyanosis on nail bed Pulse Ox 92% Lung sound diminished bilaterally in lower bases Difficulty breathing Patient in pain I think the problem seems to be neurological related to contusion or concussion from MVA and the fall may have aggravated the patient condition. I am not sure what the problem is, but we have to do something about Mrs. F. She seems unstable and can get worse. I am concerned.

R

Request / Recommendation

State your request or recommendation

I will suggest that Mrs. F should be seen by a physician ASAP or recommend a Neuro visit ASAP. I would suggest for Mrs. F to be put on O2 via nasal and monitor. Establish IV to infuse Saline Control external bleeding. Maintain patient warmth using blanket, warm IV fluids, warm room temp etc… Vs q15 min Prn if pain worsen CT scanner or MRI recommended as well Chest X ray.

Is there anything else that I should have to ad on my follow up or in my care of plan?...