ISBAR ACTIVITY STUDENT WORKSHEET

INTRODUCTION

Your name, position (RN), unit you are Hi Doctor John, My name is shahed, I’m calling from ED regarding
working on pt K.G.

SITUATION Pt K.G, 26 yrs old presented to ER 4 hours ago with a 36hr history of
vomiting and increase ileostomy output. Tachycardia and dehydration
Patient’s name, age, specific reason for the visit on admission.

BACKGROUND Pt has a history of ulcerative colitis, had a colectomy 14 months ago

Patient’s primary diagnosis, date of
admission, current orders for patient
with creation of ileostomy which he has been managing well with no
issues.
Received 2L of NS about two hours ago and currently has NS
infusing @ 125ml/hr. Also complaining of Leg cramps.
Also received 50mg gravol IV which has has been effective.

ASSESSMENT Pt is pale, tachycardic and hypotensive. Blood work show

Hypernatremia and dehydration.
Current pertinent assessment data using head Last vitals 38.1, HR, 98, 100/60, O2sat 95% on RA.
to toe approach, pertinent diagnostics, vital Repeat Blood work- awaiting results.
signs

RECOMMENDATION I think we should addres the fever and keep the patient comfortable.
Would I be able to get a Tylenol order for pt ?
Any orders or recommendations you may have I will keep an eye out for the results of the repeat blood work.
for this patient