Simulation I-SBAR
CHAMBERLAIN COLLEGE OF NURSING
Your Name: Shikinah Watson
I Your Title: Nursing Student
Reason for being there:
Introduce yourself
Patient: Janet Leiberman
S
Situation
Age: 36
Gender: F
Height/Weight: 167.6 cm/ 130lbs
Allergies: Sulfa
Attending Physician:
Dr. McGuire
Code status: Patient Chief Complaint:
Privacy Code: GI Bleed
Time:
Past Medical History: Current Medications: 2L packed RBC’s, Morphine
B
Background
Crohn’s disease
intermittent gastritis
Recent ileostomy (6 mon ago)
Sulfate 4 mg IV bolus every 2 hr PRN for pain
Social History:
Sister, no other support system
Vital Signs:
A
Assessment
94/56
B/P
110/70 110
110
HR
26
22
101.8
RR
97%
TEMP
98.8 95%
SP02
6/10
PAIN
Falls risk:____N/A_____ Accu check:___N/A____
IV Site: _____Lt forearm______IV Fluids:___1000 mL 0.9 % Sodium Chloride
150mL/hr_________________________
Isolation Isolation Precautions N Y Contact Air Droplet
RESPIRATORY Increases RR
CARDIOVASCULAR
Increased HR
NEUROLOGICAL Lightheaded and dizzy
GI/GU Voided 500mL at 1500
Hyperactive bowel sounds all 4 quad, pain in abdomen
I&O Monitor I/O
INTEGUMENTARY Pale, warm & dry
PSYCHOLOGICAL
Sister
FAMILY - SUPPORT
SAFETY Teaching needed: Avoid Ibuprofen, blood transfusion, eat a high protein diet. check vitals every 15 minutes
Abnormal: hemoglobin 7mg/dL, hematocrit 21%
LABS/TEST
Pending: hematocrit of stool
This study source was downloaded by 100000849435247 from CourseHero.com on 12-12-2022 05:43:13 GMT -06:00
https://www.coursehero.com/file/40226273/iSBAR-GI-bleeddoc/
CHAMBERLAIN COLLEGE OF NURSING
Your Name: Shikinah Watson
I Your Title: Nursing Student
Reason for being there:
Introduce yourself
Patient: Janet Leiberman
S
Situation
Age: 36
Gender: F
Height/Weight: 167.6 cm/ 130lbs
Allergies: Sulfa
Attending Physician:
Dr. McGuire
Code status: Patient Chief Complaint:
Privacy Code: GI Bleed
Time:
Past Medical History: Current Medications: 2L packed RBC’s, Morphine
B
Background
Crohn’s disease
intermittent gastritis
Recent ileostomy (6 mon ago)
Sulfate 4 mg IV bolus every 2 hr PRN for pain
Social History:
Sister, no other support system
Vital Signs:
A
Assessment
94/56
B/P
110/70 110
110
HR
26
22
101.8
RR
97%
TEMP
98.8 95%
SP02
6/10
PAIN
Falls risk:____N/A_____ Accu check:___N/A____
IV Site: _____Lt forearm______IV Fluids:___1000 mL 0.9 % Sodium Chloride
150mL/hr_________________________
Isolation Isolation Precautions N Y Contact Air Droplet
RESPIRATORY Increases RR
CARDIOVASCULAR
Increased HR
NEUROLOGICAL Lightheaded and dizzy
GI/GU Voided 500mL at 1500
Hyperactive bowel sounds all 4 quad, pain in abdomen
I&O Monitor I/O
INTEGUMENTARY Pale, warm & dry
PSYCHOLOGICAL
Sister
FAMILY - SUPPORT
SAFETY Teaching needed: Avoid Ibuprofen, blood transfusion, eat a high protein diet. check vitals every 15 minutes
Abnormal: hemoglobin 7mg/dL, hematocrit 21%
LABS/TEST
Pending: hematocrit of stool
This study source was downloaded by 100000849435247 from CourseHero.com on 12-12-2022 05:43:13 GMT -06:00
https://www.coursehero.com/file/40226273/iSBAR-GI-bleeddoc/
