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ISBAR Worksheet Mary Richards Jasgou1752 2
ISBAR Worksheet Mary Richards Jasgou1752 2
Mary Richards
Jasgou1752
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