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Danielle Young Bear ISBAR Complete
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Danielle Young Bear ISBAR Complete
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vSim ISBAR Activity Student WorksheetIntroduction
(Your name, position (RN), unit you are working Roxana Armesto, South Campus 0919
on)
Situation Ms. Young Bear's a patient of 32 years. She has a
Patient’s name, age, specific reason for visit history of low back pain as a construction worker
acquired at her job and she is also being treated
for depression. I am also worried that she is
taking a variety of prescription drugs plus a lot of
OTC medicines and using herbal treatments so
that the patient may be at risk for possible
interactions.
Background
Patient’s primary diagnosis, date of admission, Ms. Young Bear is a 32-year-old American Native
current orders of patient woman. The primary diagnosis is related to lower
back pain in chronic form.
Admission date :5/31/2020.
Orders: Obtain vital signs
Based pain evaluation of back pain in patient
Assesses neurological condition
Reconcile medicines for patients to include OTC
medicines, traditional herbal medicines and all
prescription medicines that are ordered to be
taken at home.
Draw blood samples and send them to
laboratory: monitor for liver enzymes and the
amount of serum acetaminophen. Inform the
patient that when all of the laboratory results
have arrived, we will call her.
Prescription meds:
Cyclobenzaprine 5 mg x 3 daily
Duloxetine 60 mg x 1 daily
Tramadol 50 mg x 4-6 daily
Hydrocone 5 mg/ acetaminophen 325 mg x 4
daily
This study source was downloaded by 100000840858457 from CourseHero.com on 03-10-2022 12:12:35 GMT -06:00
https://www.coursehero.com/file/63599557/danielle-young-docx/
, Assessment Ms. Young is alert and oriented. The lung sounds
Current pertinent assessment data using head to are clear bilaterally and there is a bit of redness in
toe approach, pertinent diagnostics, vital signs the throat. There is normal elasticity of the skin.
Her skin is cool and very sweaty. I also check the
back and there are no signs of serious injury. Pain
assessment-patient stated, I have like a dull sharp
pain in the lower part of my back.
Vital signs:
RR: 21
BP:113/76
Temp:99
SPO2 sat: 98%
Recommendation Rest and try not to lift heavy weights, follow all
Any orders or recommendations you may have the recommended prescription routine but be
for this patient careful of potential drug reactions over the
counter medicine and herbal remedies over.
Patient Education Worksheet
Name of medication, classification
Medication: Tramadol hydrochloride
Classification: Analgesics
This study source was downloaded by 100000840858457 from CourseHero.com on 03-10-2022 12:12:35 GMT -06:00
https://www.coursehero.com/file/63599557/danielle-young-docx/
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