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ISBAR Assignment

Week 8 Introduction to Documentation

Thea Yvonne Lacangan (20162887)

University of Cebu Mandaue and Lapu-Lapu Campus

Nursing Informatics

Instructor: Domino Puson, R.N., M.N.

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ISBAR (Clinical Communication)

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.

I Identify Self (name, position, Hello doc, good morning, how are you.
location) I’m Thea Yvonne Lacangan the nurse at
the Medical Unit from the emergency
Patient (name age,
department, taking care of Mr. Kenneth
gender)
Bronson, a 27-year-old male.

S Situation Explain what has I’m calling to let you know that the
happened to trigger patient is experiencing chest tightness,
this phone call difficulty breathing, a productive cough
conversation for a week, swelling throat where he
can’t breath properly and with a
temperature of 102 °F

B Background Admission date, The patient has no medical history and

diagnosis, relevant no allergies. no medications taken before
history, hospitalization . He showed himself to the
investigations, what emergency department 12 hours ago,
has been done so far Chest X-ray revealed right lower lobe
pneumonia. He is receiving oxygen at
2.1/min per nasal cannula. infusion of
75ml per hour of normal saline. SpO2 on
room air was 90%, which increased to
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93% with supplemental oxygen. He was

given 1,000 mg of acetaminophen and an
infusion of cetriaxone has been started.

A Assessment Give a summary of Patient’s skin feels hot to the touch and
the patient’s sweats profusely. Patient has been
condition or suffering from cough chest tightness,
situation. Explain difficulty breathing for the past few
what you think the weeks. Patient stated that he feels that
problem is (if you his throat is expanding. His Radical
can) pulse is 95 per minute, the pulse oximeter
is 17 bpm, The chest moving normally on
both sides. His blood pressure is 136/82
mmHg. The sound of his right lung was
reduced at the right lung base.

R Request/ State your request or Given the current situation of the patient,
recommendation I would recommend that the patient
Recommendation
should be transported to the critical care
unit or ICU due to the nature of the
patient’s condition, which would change
drastically in the next hour. In your orders
doc, please provide an oxygen titration
process. The patient seemed to be
battling from pneumonia. Please see the
patient right away and educate the
patient and patient’s family members
about the treatment again.

-Kenneth bronson, 27 year old male , oct 5 1994

-diagnosis: pneumonia

-location: medical unit

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-the pt was experiencing chest tightness, difficulty breathing, a productive cough for a week, and a
fever.

-chest x ray revealed right lower lobe pneumonia

-interventions: Iv was started of normal saline at 75ml per hour. He is receiving oxygen at 2L/min per
nasal cannula. Spo2 on room air was 90%, which increased to 93% with supplemental oxygen. He had
a temp of 102 degrees farenheut and was fiven acetaminophen 1,000 mg in the emergency
department. Pharmacy just delivered the antibiotics to be given

INTERVIEW WITH THE PATIENT:

-pt requested for antibiotics

-no allergies and no medical history

- coughing starting to get worst about a week ago and started having a fever

-other symptoms: tired and chest tightness

-just ate breakfast

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-no medications before hospitalization

- it hurts when he breaths where it stings a bit in his chest, in the right side of his chest.

- pain scale of 2

-temp of 102

-pulse rate of 95

-pulse oximeter 17 bpm

-blood pressure of 136/ 82 mmhg

- the site has no redness, swelling or any infiltration

-infusion of 75ml per hour of normal saline is runnning

- chest moving normally both sides

-he is sweating profusely and the skin is warm

- reduce breath sounds at the right lung based

-1000ml acetomenophine has been given

- an infusion of cetriaxone has been started

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-his throat is swelling where he cant breath

- attaching blood pressure cough to monitor blood pressure continuously

- then calling provider

TO THE FILIPINO YOUTH:

I CHOSE THis literary work ENTITILED TO THE FILIPINO YOUTH. ThIS poem implies confidence in the first
few stanzas and IN MY DRAWING AS YOU CAN SEE THERE are two TWO FACES. ONE IS FACING BELOW
AND ONE IS FACING ABOVE. MY INTERPRETATION AND EXPLANATION ABOUT MY DRAWING IS THAT
THIS IMPLIES THAT some YOUTH IS SILENT, AND CONSEQUENTLY HAS has not yet gone into full bloom for
whatever reason there is that may have silenced them. ( naay uban kay sobra ra ka mauwawon, uan ay
mahadlok majudge sa others and naa puy uban nga ga struggle inside if they will show or not what they are
capable of) BUT THIS POEM encourages the youth, by telling them to hold their heads high for they possess
talents and skills and abilities that would make their country proud. And for me confidence is a feeling or belief
that someone or something is good or has the abuility to succeed at something.

http://thelifeandworksofrizal.blogspot.com/2013/06/interpretation-to-filipino-youth.html