ISBAR GI bleed Final- Lieberman, Janet A-36 years old-2024-2025.docx, Exams of Advanced Education

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• ISBAR GI bleed Final- Lieberman, Janet A-
  • years old-2024-202

I

INTRODUCE

YOURSELF

YourName: (^) Leslie Lopez Your Title: (^) Student Nurse Reason for Being There: (^) Patient Care

Patient: Lieberman, Janet A.

History of Current Problem:

Traces of blood were

present in her ostomy

bag.

Age: 36

S

SITUATION

Gender: Female

Height/Weight: 167.6cm (66 inches)/ 59kg (130 ibs)

Allergies: Sulfa

Code status:

Privacy Code: 534689

Time: 1500

Attending Physician: McGuire, Mark

Patient Chief Complaint : Abdominal pain , dizziness and blood in stool

Chief Informant: Family History: Has a sister that is on her way to the hospital

B

BACKGROUN

D

Past Medical History: Chrons diease, Intermitten gastiritis, Iliostomy 6months ago. Current Medications: Remicade q 8weeks last dose 7weeks ago, otc anti inflammatory Morphine 4mg q2hr prn for pain Social History: Drinks alcohol in the evenings to release stress VITAL SIGNS:

A

ASSESSMEN

T

B/P HR RR TEM

P

SP02 PAIN

94/56 11 0 26 98.6^ 95% FALLS RISK Y N IV^ Site:^ L^ arm^ Accu check: IV Fluids:

1000ml 0.9% sodium chloride at 150ml

per hr

ISOLATION (^) Isolation Precautions: Y N Contact Air Droplet HEENT Alert^ and^ orientated^ X3,^ normocephalic,^ EENT-^ WNL,^ Mouth^ and^ throat-^ pink,^ dry^ mouth, nolesions, Uvula rises on phonation. RESPIRATORY Breathing^ sounds^ clear^ no^ adventitious^ sounds CARDIOVASCULAR HR^ elevated,^ S1^ and^ S2^ normal NEUROLOGICAL (^) Exam intact GI/GU I & O Abdomen- soft, flat, no apparent masses. Hypepractive bowl sounds present, Tympany and percussion in all 4 quandrants , Liver and spleen palpated no masses, Moderate overall abdominal tenderness, no rebound tenderness or gaurding. Ileostomy present on the lower right side of abdomen draining semi liquid stool with red streaks MUSCULOSKELETAL Exam^ intact INTEGUMENTARY (^) Skin smooth, fair, dry and pale. Nail beds pink, good capillary refill. LYMPHATIC (^) Reviewed within normal limit, continur to monitor ENDOCRINE Reviewed, within normal limits. Continue to monitor. PSYCHOLOGICAL FAMILY - SUPPORT Has^ asister^ that^ is^ her^ support^ system SAFETY Educated patient on new ways to cope with her stress which caused her current symptoms

LABS/TEST Abnormal: Fecal ocult blood, Ptt , Hbg, RBC, Hct, MCHc Pending: Ordered

R

REQUEST/

RECOMMENDATIO

N

Hand off report to: From: ©2016 Chamberlain College of Nursing LLC. All rights reserved.