UPDATED 2024 ISBAR GI bleed Final,Patient ;Lieberman, Janet A,36YRS, Female EXPERT FEEDBAC

I INTRODUCE YOURSELF YourName: Your Title: Student Nurse Reason for Being There: Patient Care Patient: Lieberman, Janet A. History of Current Problem: Traces of blood were present in her ostomy bag. Age:36 S SITUATIO N Gender: Female Height/Weight: 167.6cm (66 inches)/ 59kg (130 ibs) Allergies: Sulfa Code status: Privacy Code: 534689 Time: 1500 Attending Physician: McGuire, Mark Patient Chief Complaint: Abdominal pain , dizziness and blood in stool Chief Informant: Family History: Has a sister that is on her way to the hospital B BACKGRO UND Past Medical History: Chrons diease, Intermitten gastiritis, Iliostomy 6months ago. Current Medications: Remicade q 8weeks last dose 7weeks ago, otc anti inflammatory Morphine 4mg q2hr prn for pain Social History: Drinks alcohol in the evenings to release stress VITAL SIGNS: A ASSESSME NT B/ P HR RR TE MP SP0 2 PAI N 94/.6 95% FALLS RISK Y N IV Site: L arm Accu check: IV Fluids: 1000ml 0.9% sodium chloride at 150ml per hr ISOLATION Isolation Precautions: Y N Contact Ai r Droplet HEENT Alert and orientated X3, normocephalic, EENT- WNL, Mouth and throat- pink, dry mouth, nolesions, Uvula rises on phonation. RESPIRATO RY Breathing sounds clear no adventitious sounds CARDIOVAS CULAR HR elevated, S1 and S2 normal NEUROLOGI CAL Exam intact GI/GU I & O Abdomen- soft, flat, no apparent masses. Hypepractive bowl sounds present, Tympany and percussion in all 4 quandrants , Liver and spleen palpated no masses, Moderate overall abdominal tenderness, no rebound tenderness or gaurding. Ileostomy present on the lower right side of abdomen draining semi liquid stool with red streaks MUSCULOS KELETAL Exam intact INTEGUMEN TARY Skin smooth, fair, dry and pale. Nail beds pink, good capillary refill. LYMPHATIC Reviewed within normal limit, continur to monitor