You are assigned to Mr. M. a 79-year-old man who was admitted today to your unit for a urinary tract infection and urosepsis
11PM – 7AM Handoff Nursing Report:
Patient has been agitated and anxious during the night. He was restless and kept trying to get out of bed. He seemed confused and disoriented. He was moved closer to the nurses’ station to assist with frequent monitoring. The 0600 vital signs are T 38 C, P 78, R 22, BP 146/88, denies pain. His 0700 pulse oximeter reading was 96% (room air) and he has an IV of lactated Ringers infusion at 100 mL/hr. Cefriaxone 1g IV qAM is ordered.
Subjective data
Objective data
Diagnostic studies
Nursing Kardex
Name: Mr. M
Age: 79
Diagnosis: Urinary Tract Infection and Urosepsis
It is now 0730. As you enter his room you notice he is restless and seems disoriented.
As you provide morning care to Mr. M you note the following signs and symptoms:
Follow-up action plan:
Using ISBAR, inform the physician about what is going on with the patient, ONLY ASSESSMENT AND REQUEST/RECOMMENDATION PART.
BE CLEAR, CONCISE, AND ACCURATE WITH WHAT YOU WOULD LIKE TO TELL THE PHYSICIAN
Remember you are not diagnosing your patient but providing information to the doctor
The doctor is not there so provide relevant information necessary to support your requests
Do NOT simply ask for the doctor to come and see their patient - Tell the doctor what is going on and what you need so the patient is getting the care required before the doctor arrives
ISBAR is a communication technique for communicating critical clinical information.It is an abbreviation for indentification, situation, Background, Assessment, Recommendation.
So the communication of Mr M will be as follows .
Identification:Good Morning I'm abc the unit nurse and I wanted to inform you about 79 year old Mr M admitted yesterday with urosepsis .
Situation:The reason why I'm calling you it's to inform you that this patient looks disoriented ,drowsy and restless with a low saturation level and hypotension
Background:patient was admitted with burning micturation with hematuria,pain at the flank region yesterday lab work up shows pyuria and hematuria.he is on Ringer lactate on flow at 100ml/he ,inj cefriaxone 1gm BD ,and. acetaminophen sos for fever .He was ambulatory with minimal assistance and on soft diet .has a family history of Ca Kidney and renal failure .
Assessment: Patient has ,crackles audible on auscultation,has vital signs of T 39.1 degree C,pulse : 130 beats/min,Resp:28b/m,BP : 90/54 mmhg, Saturation of 88%.with warm and flushed skin and low urine output
Recommendation:can you come and see in the patient in the mean time should I discontinue the fluid as fluid overload may be a reason,can I start Oxygen through nasal prongs and then keep intubation ready till you come .is their any lab investigations to be send before you come .Is their any other intervention that you want me to do till I wait for your visit.
You are assigned to Mr. M. a 79-year-old man who was admitted today to your unit...
You are assigned to Mr. M. a 79-year-old man who was admitted to your unit for a urinary tract infection and urosepsis. He has been agitated and anxious during the night. He was restless and kept trying to get out of bed. He seems confused and disoriented. He was moved closer to the nurses’ station to assist with frequent monitoring. 6 AM vitals: T 38C, P 78, R 22, BP 146/88, denies pain. 7 AM pulse ox. 96% (room air)...
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Mr. Raymundo Gonzales, an 84 year old Hispanic male is admitted to your unit with a diagnosis of “Sepsis, origin Unknown.” You document your assessment findings which include the following. Patient is confused, disoriented & restless T-98.9, P-98, R-28, B/P 90/58, Pulse Ox 92%, unable to determine a pain level but grunted & moaned upon abdominal palpation Abdomen firm and rigid Skin warm and dry with scaly patches He urinated 50 ml of cola colored urine He has bilateral crackles...
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Mr. McClaren is a 48-year-old man who is admitted to the emergency department (ED) with abdominal pain and general weakness. He reports that he drinks “one bottle of scotch whisky every week for the past one year, and one to two cans of beer during the weekends.” For the past three months, his condition has started to deteriorate. His wife claims that “he has not been eating well for the past three months”. Mr. McClaren reports he has passed dark...
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