Isbar Respi Mr. J PDF

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ISBAR...

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ISBAR Assignment Template – Health Assessment 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? At 0930 the physician calls you back. Using the ISBAR sheet, write how you will communicate with the physician over the phone I

Identify

Self – name , position, location Patient – name, age, gender Explain what has happened to trigger this phone call conversation

This is Maricar Estoque. I am calling about Mrs. J., 88 years old female, who was admitted from Long term care facility.

S

Situation

B

Background

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

Assessment

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

Patient was admitted last evening from long term facility. Recent UA culture reports showed + MRSA. Patient was lethargic and confused. Admitted with fever T= 101F, P 92 irregular R 28 short and shallow, BP 110 /70 , SPO2 94%. She is on acethaminophen 325 mg tabs ii q4h PRN, on IVF 0.9 %NS @ 75ml/hr with #24 angiocath R forearm. CBC and chem panel done. Mrs. J slept 1-2 hrs during the night and remain confuse. She developed productive cough with small amount of thick creamy yellow phlegm. Her morning vital

A

She has developed a productive cough and is expectorating a small amount of thick, creamy, yellowcolored phlegm.

signs are T 100.8° F, P 110, R 32, BP 114/82, pulse ox 92% I think

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Request / Recommendatio n

State your request or recommendation

patient has pneumonia. Dr. I believed we must do the following actions: 1. Oxygen 2 L/min/NP

2. 3. 4. 5.

Monitor v/s Monitor SPO2 Chest Xray

ECG

6. Vancomycin 500 mg q8h

IVPB 7. Increase fluid intake 8. Monitor I &O 9. Bedrest...