Lorem

Introduction of Disease

Age and reason for hospitalization (medical diagnosis):

Nursing concept that is connected to reason for hospitalization:

Safety-Communication-Infection Control

Communication elements:

Safety concerns:

Infection control practices:

Assessment: Recognize/Identify cues

Identified cues:

· Cue 1

· Cue 2

· Cue 3

· Cue 4

· Psychosocial Cue

Nursing Diagnosis: Analyze Cues/ Prioritize Hypothesis

Cue/ area of concern that is high priority:

Cue/ area of concern that is medium priority:

Cue/ area of concern that focuses on psychosocial problem/need:

Rationale for why these areas of concern/cues were chosen and prioritized as high, medium or psychosocial and how they connect to the client:

Planning: Generating Solutions

and

Implementation: Taking Action

Cue/area of concern that is high priority:

S.M.A.R.T. goal:

Rationale for goal:

Client specific intervention:

Cue/area of concern that is medium priority:

S.M.A.R.T. goal:

Rationale for goal:

Client specific intervention:

Cue/area of concern that is psychosocial:

S.M.A.R.T. goal:

Rationale for goal:

Client specific intervention:

Evaluation: Evaluating Outcomes

Explain if goals were met or not:

Supportive evidence:

Changes needed to achieve goals in the future:

I-SBAR

I – Introduce Yourself

Your Name:

D#:

Your Title: Nursing Student

Reason for being there: Clinical rotation, patient assessment

S – Situation

Patient: J.S.

Attending Physician: Dr. Patel, Gastroenterology

Age: 28 years old

Patient Chief Complaint/Primary Medical Diagnosis and Clinical Significance:

Admitted for acute flare of Crohn’s disease with abdominal pain, diarrhea, and weight loss. Risk for dehydration, malnutrition, and bowel obstruction.

Gender/Identity: Male

Height/Weight: 5’9” (175cm) / 132 lbs (59.8 kg)

Allergies: NKDA

Code Status: Full

Advance Directive (durable power of attorney, living will, other) and Clinical Significance:

None on file

Pathophysiology of Primary Medical Diagnosis:

Crohn’s disease is a chronic, relapsing inflammatory bowel disease (IBD) characterized by transmural inflammation of the GI tract, commonly affecting the terminal ileum and colon. Leads to malabsorption, strictures, fistulas, and systemic complications (e.g., anemia, malnutrition

Privacy Code: 4125

Date of Care/Time: 8/29/2025 - 1500

B – Background

Include clinical significance with each:

Past Medical History: Crohn’s disease (diagnosed age 21), anemia of chronic disease, anxiety

Past Surgical History: Appendectomy age 10

Immunizations Received: Up to date, received influenza vaccine last fall; no pneumococcal vaccine documented

Social History/Socioeconomic Factors: Lives alone, works part-time as barista. Smokes ½ pack/day (risk factor for Crohn’s flare), occasional alcohol, no illicit drug use. Limited financial resources—difficulty affording medications.

A – Assessment

Vital Signs:

B/P

HR

RR

TEMP

SP02

PAIN

102/64 mmHg

112 bpm

22/min

100.8°F (38.2°C)

97% RA

7/10 cramping abdominal pain

Fall Risk: Moderate (weakness, dehydration, tachycardia)

Accu-check: 92 mg/dL

IV Site: 20g L forearm, patent, site clean/dry

IV Fluids: NS @ 100 mL/hr

Lab/Test Results:

 CBC: WBC 13.2 (↑), Hgb 9.8 g/dL (↓), Hct 30% (↓), Platelets 420 (↑)

 CMP: Na 134 (slightly ↓), K 3.4 (↓), Albumin 2.9 (↓), Creatinine 0.9

 CRP: Elevated

I and O

Intake 1.5 L IV; Output 800 mL urine, 5 watery stools in past 24 hr

Isolation

Isolation Precautions: Y ☐ N ☒

Contact Air ☐ Droplet ☐

RESPIRATORY

Clear bilaterally, no distress

CARDIOVASCULAR

Tachycardic, regular rhythm, pulses 2+

NEUROLOGICAL

Alert, oriented ×3, fatigued

GI/GU

Abdomen tender, hyperactive bowel sounds, diarrhea x5, reports poor appetite, no blood in stool noted this shift

INTEGUMENTARY

Pale, dry mucous membranes, skin intact, slight periorbital dark circles

PSYCHOLOGICAL FAMILY – SUPPORT

Mother visits daily, patient reports stress related to frequent hospitalizations and missed work

SAFETY

Teaching needed: Importance of medication adherence, smoking cessation, nutrition/hydration strategies, recognizing early flare symptoms.

Call light within reach, bed low, side rails ×2

R – REQUEST/ RECOMMENDATION

Hand off report to: Nursing Student

From: RN