NUR 1022C Millie Larsen ISBAR

ISBAR Worksheet: Interdepartmental Communication This is not part of the medical record Sunshine Community Hospital Patient Name: Millie Larson Date: 04 /16 /2020 Time: 9:00 AM Location: Sunshine Community Hospital Pre-call preparation:  Gather the following information: Patient's name; age; allergies; medical record  Rehearse in your mind what you plan to say. Run it by another nurse if unsure.  If calling about pain, when and what was last pain medication?  If calling about fever, what was the most recent temperature?  If calling about an abnormal lab, what was the result of the last test?  What is the goal of your call?  Remember to start by introducing yourself by name a location. Use area below as a checklist to gather your thoughts and prepare. I Introduction: Who you are, your role, where you are and why you are communicating? S Situation: What is happening at the moment? Give a clear, succinct overview of pertinent issues. I am calling about Millie Larson. Mrs. Larson currently has no pain, has a low-grade fever at 100.8 degrees F, elevated BP of 180/110, O2 sat of 94%, elevated WBC at 12, low hemoglobin at 9.9, and low hematocrit at 32. B Background: Briefly state the pertinent history. What are the issues that led up to this situation? Mrs. Larson is an 84-year-old female who lives at home, he has hypertension, glaucoma, osteoporosis, arthritis, elevated cholesterol, stress incontinence and is suffering from confusion since last night. A Assessment: Summarize the facts. What do you think the problem is? Use your best judgment. Mrs. Larson has confusion, BP of 180/110, elevated specific gravity urine at 1.050, O2 sat of 94%, WBC of 12, temperature of 100.8, p of 98 and respirations of 16. With the elevated WBC count and the confusion, I believe Mrs. Larson has contracted an infection. With the elevated specific gravity urine, I believe Mrs. Larson is dehydrated. R Recommendation: What should be done to correct this situation? What actions are you asking for? What do you want to happen next? Would it be possible to have an order for antibiotics to treat the infection, give medication to decrease her high BP, and give IV fluids to treat her dehydration? Also, I would want to double check labs and vitals and look at the medications that are going to be given to her