Isobar clinical handover PDF

Preview

Summary

Download Isobar clinical handover PDF

Description

Case study 1 -

I

Identity - introduce yourself and -

S

your position the patient: name, age, gender

Situation - what has happened to trigger this conversation

O

Observation - observation include all relevant subjective and objective data

B

A

Sophie Marshall RN student nurse, ward 6A.

Background -

admission date diagnosis relevant history investigation what has been done so far

Assessment - summary of the -

persons condition or situation explain what you think the problem is

Erin Musk 65yr female.

Pt presented with pneumonia two days ago. Abnormal observations - Presented with tachypnoea - Presented with hypoxia

Vital signs abnormal - resp 28 bpm on arrival - O2 sat 82% room air on arrival - Monitor IV canula sight -

Admitted two days ago No relevant past medical history. Diagnosed with pneumonia commenced (IV’s AB’s) today. I have applied 2 L’s of oxygen via N/P (nasal prongs) Saturations currently 97% oxygen therapy for hypoxia IV AB’s for pneumonia Tachypnoea currently under observation

R

Recommendation - state your request

- Erin will be under daily review by the doctor - IV Medications as per doctors’ orders - Continuation of O2 therapy as per med chart, reviewed daily - Continuation of regular observation as Dr orders and per rainbow observation chart - Monitor IV canula sight...