ISBAR ACTIVITY STUDENT WORKSHEET

INTRODUCTION
Good afternoon, Dr. S., my name is Marina, and I am a student
Your name, position (RN), unit you are registered nurse on 2B surgery. I am calling about the patient by the
working on window in room 211

SITUATION
G. D. is a 23-year-old male that has been in the hospital for the last 4
Patient’s name, age, specific reason for the visit weeks due to malnutrition and inadequate coping.

BACKGROUND
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT
Current pertinent assessment data using head
to toe approach, pertinent diagnostics, vital
signs
RECOMMENDATION
G. D. was diagnosed with colon cancer 8 weeks ago and underwent a
surgical ileostomy creation 3 weeks ago. He has a history of G.E.R.D.,
anorexia, and now colon cancer. His ileostomy is in the right lower
quadrant of his abdomen. It began draining 400mL of soft, green
drainage qshift 12 hours post-operatively. It was noted immediately
that G. D. refused to aid nurses in the emptying of his ileostomy or in
care. He began decreasing his intake, and eventually 2 weeks post
operatively began TPN for nutrition in addition to receiving a low
residue diet tray with meals. He previously had issues with fluid and
electrolyte imbalance related to his anorexia. He weighed 77kg on
admission. His current orders include pantoprazole 40mg PO OD,
Imodium q4h PRN, and TPN q24h. Vital signs post-operatively on day
one was stable with: temperature 36.8 degrees Celsius orally, BP
117/78, HR 79 bpm regular, respiratory rate of 17, and an oxygen
saturation of 100% on RA. His chest was clear, with a clear chest,
regular heart rate, and active bowel sounds to all quadrants. We were
able to remove his indwelling catheter on post operative day 2 due to
his adequate output.
On assessment, the G. D. is pale with dry mucous membranes. He
remains alert and oriented. His abdomen is flat, and his stoma is pink
and dry. The peristomal skin is dry and macerated, pink, and painful.
The drainage from the stoma is thick, brown stool. His output qshift is
x1 large lumpy, sausage stool that is brown. His current weight as of
today is 71.6kg. His vitals are as follows: temperature 36.5 degrees
Celsius orally, BP 90/50, HR 106bpm regular, respiratory rate of 14,
and an oxygen saturation of 96% on RA. His chest remains clear with
an irregular heart rate apically and hypoactive bowel sounds. He is
currently having chest pain. G. D. has poor urine output and is
currently retaining 400mL of urine. His electrolyte levels, including
his sodium, potassium, and magnesium levels are: Na 115mEq/L, K+
6.7mEq, and Mg 1.2mg/dL. Additionally, his two laparotomy sites
show signs of infection, with redness and warmth on palpation and
purulent, white discharge. G. D. is refusing to help nursing staff with
ADL’s and is refusing to aid in ileostomy care. He remains in bed and
refuses ambulation. He presents weak with no motivation.

Any orders or recommendations you may have
for this patient
Dr. S., would it be possible to start a maintenance intravenous solution,
such as lactated ringers, to supply electrolytes to G. D. and prevent
further electrolyte imbalance? Additionally, maybe his electrolytes can
be replaced today intravenously and Kayexalate
provided to decrease his chest pain and K+ levels. An ECG may allow
us to assess his cardiac rhythm more accurately. He may benefit from
antibiotics for a possible infection to his laparotomy sites. I think the
insertion of another indwelling catheter may be helpful so we can
monitor his output accordingly. The nursing staff can monitor his
caloric intake and encourage foods he enjoys, promoting healthy eating
habits. A mental health and dietician consult may prove to be
beneficial to assess if he is falling into eating disorder habits. They
may be able to place G. D. in a support group or program that supports
a healthy body image and healthy eating. I feel as though G. D. would
benefit from a visit from you for education and discussion on future
steps.