Point of care from Nurse to Doctor

ISBAR ACTIVITY
STUDE
NT WORKSHEET

INTRODUCTION
• Gabriella, RN

• Med-Surg Unit
Your name, position (RN),
unit you are working on

SITUATION • Mrs. Anne Davoski

• 65 – year old female

• 5-day history of increased fatigue,

• sputum production- a change in the character of

Patient’s name, age, specific reason for sputum
the visit
• increased shortness of breath

• fever of 38.9

• Currently having abnormal BP

BACKGROUND • Pneumonia Primary Diagnosis

• Past medical Hx - History of COPD, bronchitis,

HTN, on hydrochlorothiazide and Metoprolol,
some LV CHF, Type 2 Diabetic since menopause -
diet controlled, Mild cataracts, some slight memory
loss of recent events.
Patient’s primary diagnosis, date of
• 2 previous COPD admission
admission, current orders for patient
• Current - K+ decreased, BP elevated – cardiology
consulted

• 10-year hx of high blood pressure – managed with

medication

ASSESSMENT • Alert and oriented X3,

 • bilateral fine crackles throughout chest,

• air entry decreased in both bases bilaterally

• Normal lab values

• Currently on antibiotic

• Hypertension
Current pertinent assessment data
using head to toe approach, • Recent vitals
pertinent diagnostics, vital signs
o 166/86
o 88 pulses
o 26 RR
o 94% on Room air
o 36.6 c temp

RECOMMENDATION
• Upset with medication

• Cardiology should be seeing her today

Any orders or recommendations you
• Write cues on board for patient to remember d/t
may have for this patient
short memory loss