Question

Handoff report at 0800. Young man transferred from ICU for a motor vehicle accident 14 days ago. Head trauma, subsequent evacuation of subdermal hematoma. Currently unconscious, unresponsive to painful stimuli, flaccid extremities. Pupils round, sluggish reaction to light. Abrasions on face, bruises on shoulder and chest. VS: T 98.9°F, P 94, R 24, BP 124/80, pulse ox 94%. Mother at bedside, questions everything you do.

2:00 PM nursing assessment: Pupil round R ● L ●nonreactive to light. R 12 Cheyne-Stokes, P 80, BP 150/80. Skin warm, jerky movements of the upper extremity noted. The physician writes the following orders:
Oxygen at 12 L/min per non-rebreather mask
Check oxygen saturation q1h
Vital signs q1h
CT scan of the head stat
ABGs stat

Using ISBAR, write how you will communicate with the patient’s primary health care provider/physician over the phone?

I	Identify	Self – name , position, location Patient – name, age, gender
S	Situation	Explain what has happened to trigger this phone call conversation
B	Background	Admission date, diagnosis, relevant history, investigations, what has been done so far
A	Assessment	Give a summary of the patient’s condition or situation. Explain what you think the problem is (if you can)
R	Request / Recommendation	State your request or recommendation

Answer 1

Patient with Motor vehicle accident recived from ICU and staff nurse of ICU given hands off report.Communicating about respective patient to the physician in following steps.

Identification details:

• Introduction about ours is important for recognition by physician eh.Am staff nurse from**ward ,and my name miss.****.these details may help to know patient was in which ward
• Details about patient: patient name Mr.***,age :** male patient recived to tge ward from icu ,with the complaints of head injury by motor vehicle accident,subsequent evacuation of subdural hematoma. Situation of the patient at present Currently patient was unconscious unresposive to painful stimuli,flaccid extremities.pupils round and sluggish reaction to light And Vital science are Tempratur: 98.9 f pulse: 94 Respiration :24 Blood pressure: 124/80 .Pulse oxy 94%
• Background of the patient: back ground of the same patient was when he was admitted what are the investigations done and what is the treatment is given till now helps to revise the treatment
• Assessment of patient: assessment of the patient what we done at 2 pm ...right pupil round nad left non reactive to light,cheynestokes,pulse 80,BP 150/80 ,skin warm,jerky movement's of upper extremities thses complaint's from the patient

expailn about the present treatment and present condition of the patient

Request: Asking with the physician what treatment has to give now to this patient ????