I-SBAR-R Diana Humphries, 45 years old PDF

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Clinical work, for Basic Adult health care...

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I-SBAR-R Identification: Identification of yourself: Joshua Loebel, Nursing Student, N/A, Diana Humphries, 45 years old

Situation: Name/age: Diana Humphries, 45 years old BRIEF summary of primary problem: the pt. came in with generalized abdominal pain, nausea, emesis Increased thirst, appetite, urination and her lunchtime glucometer gave no reading because too high.

Day of admission/post-op #: March 3, 2021

Background: Primary problem/diagnosis: Diabetic Ketoacidosis Diabetic Ketoacidosis occurs in type 1 diabetics. This is when there is a significant increase in blood glucose levels due to the lack of insulin. Glucose accumulates in the blood result in the metabolism of ketones. Ketones will then accumulate in the blood resulting in acidosis. The increase in acidosis will then contribute to other complications such as shock and ultimately coma/death.

RELEVANT past medical history: pt. has chronic kidney disease stage III and diabetes mellitus type1 RELEVANT background data: pt. is Divorced, Homeless and lives in a shelter, Inconsistent with medication regimen.

Assessment: Current vital signs: T: 101.6 F/38.7 C (oral) Provoking/Palliative:

Coughing and deep breathing/Not coughing

P: 114 (regular)

Quality:

Sharp

R: 24 (regular/deep)

Region/Radiation:

Right chest

BP: 102/66

Severity:

5/10

O2 sat: 90% Room air

Timing:

Intermittent

R 24 (high), T 101.6 ( high), P 114 ( high), O2 sat: 90% Low due to her increased RR, productive cough, Low BP, Pain 5/10.

RELEVANT body system nursing assessment data:

General appearance - anxious and uncomfortable, tense, grimacing RR - clear with coarse crackles in RLL, hard productive cough with thick yellow sputum GU - frequent urination, clear in color GI - nausea is persistent Skin - lips are dry and tacky

RELEVANT lab values: Complete Blood Current: Count (CBC):

HIGH

9.8

Hgb (12–16 g/dL) 11.8

LOW

11.2

Platelets (150– 450x 103/µl)

155

NORMAL (LOW)

162

Neutrophil % (42–72)

92

HIGH

70

Band forms (3– 5%)

3

HIGH

1

WBC (4.5–11.0 mm 3)

15.2

High/Low/WNL Prior: ?

TREND of any abnormal clinical data (stable-increasing/decreasing): Worsening How have you advanced the plan of care? I have advanced the plan of care for the pt by retrieving and sending to labs Blood glucose, 12 lead EK, place patient on a cardiac monitor and Established a IV and initiate NS 0.9% bolus of 1000 mL.

Patient response: Patient has tolerated interventions well. INTERPRETATION of current clinical status (stable/unstable/worsening): Stable

Recommendation: Suggestions to advance plan of care: I recommend the pt. be educated during stay at hospital about the importance of medication compliance, as well as bring in a social worker since she is homeless and does not have proper housing.

Repeat-Read back: Repeat-Read back to confirm-plan of care:

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