Nursing

ISBAR

I

Identify

My name is Sekinot Mohammed, the nurse in charge of the patient during this shift.

S

Situation

The patient name is Christine A Jordan, a 75 years old female, full cold allergies to pyridine, transferred from ED after fall’ She has a fracture on her tibia and sprained her right wrist. She is on call to the OR for an open reduction and internal fixation surgery which will last for 2 hours.

B

Background

The past medical history is high cholesterol and hypertension. She is hard of hearing.

A

Assessment

She is alert and oriented. The heart rate is regular and the lungs are clear, positive bowel sound. The left foot is slightly cold but pink plus two pedal pulses but no edema. Her right wrist slightly swollen and all the other extremities are within define limit. Pain overnight has been within 3 and 4 out of ten, he was well control with the morphine she received from ED. She does have oxycodone tablet that she received every 4 hours as needed, her last dose was given at 6 a.m. this morning. She has 2 intact IV in her left forearm, one saline locked and the other one is the five ½ normal saline with 20fk running at 100ml/hr and she has urinary catheter.

R

Recommendation

The patient is placed on a risk for fall. Her diet is NPO before operation. The goals after the surgery will be to discontinue the urinary catheter to prevent the catheter associated with UTI and also to manage pain.