University:
American Career College
Course:
NURS-113 | Beginning Medical/Surgical Nursing
Academic year:

2022
Views:

458

Pages:

1
Author:

kundgetanufv

ISBAR I-Hello, my name is Astrid, I am a nurse in the medical surgical unit at Shadow General hospital. I am calling to give report on your new patient. The patients name is Elias Joseph, he is 28 years old. S- the patient presented to the ER with abdominal pain in the lower right abdomen two days ago. Patient was diaphoretic and stated a pain of 10/10. Patient is currently stable. B- Patient began experiencing sharp pains in the RLQ two days ago. Patient arrived at the hospital at 18:20 , 02/02/2021. The patient was admitted at 02:33 02/03/2021. The patient was diagnosed with Appendicitis and was scheduled for an appendectomy 02/03/2021 at 17:00. Patient had procedure done and came out successfully. Patient is now in recovery. patient is allergic to penicillin and has a history of asthma, A- Patient seems to be recovering well. Incision sight needs monitoring. Last vital signs were BP: 120/75; RR: 13; O2:99%; Temp. 98 F; pain scale rating 4/10. Currently patient has been taking medications. He is taking ibuprofen 800 mg. heparin. R- patient should be able to report 0/10 by the next day. Patient should also be able to ambulate without discomfort. Patient will continue to take ordered medications as prescribed and will have a CT exam to see progress. Vital signs and labs should be monitored. They should be reviewed by attending physician. The patient is to be discharged once a cleared by physician.