ISBAR worksheet

Mary Richards

Jasgou1752

Introduction Hello, my name is Jasmyn Gould (SN) RN at ECPI ED

Situation Kim Johnson is a 26-year-old AA female. Admin of 9/10/2020 to ED by

son when He found her confused and c/o oftrouble with her vision. Pt.
Has been ill for several days with c/o nausea, dizziness, in weakness

Primary Dx- Cystic

Background

fibrosis
Admitted on
04/18/2020
Orders- Vital signs
every 4 hours, daily
input and output, daily
weight, chest X-ray,
NG tube insertion.
Diet-high calorie, high
protein, regular diet,
supplement with high
protein snacks. Fluid
 nutrition (1.5 kcal) 720
kcal over 8 hours
during
the night. Snack
consisting of 2
multivitamin tablets
provided PO
every morning
Medications:
Pancrelipase enzymes 5
capsules PO before
meals and
tube feedings, 3
capsules PO with
snacks
Ms. Richards has c/o of abd. pain and nausea, with no emesis
Assessment VS:
 Heart Rate: 62
 BP-101/60 mm Hg
 T- 99 F
  RR- 12 equal
 Pulse-present strong and reg
 Pain: 0/10
 Heart/lung sounds: ECG: sinus rhythm. WNL
 SpO2- 97% on on room air
 Paint- none
 Skin- All normal findings, normal turgor
 Pt. can trans
Meds given
 Admin. 4 MG of ondansetron IV push
 Admin. Potassium chloride 10 mEq in 100 mL

Recommendation I would recommend

Continuous monitoring a patient, as well as patient education of
signs of toxicity and importance of follow-up care .