Additional information for the Documentation and ISBAR section assigned:
- Use the DAR Focused note form:
- Document up to this point following the principles of documentation.
- Then, include the Additional information to complete all steps of the documentation process for the priority problem.
- Document only the priority problem in a focused note format: DAR. The priority problem should be fully documented on the Focused note template using this method.
- Do not include a new or a different problem.
- You have been working on the ISBAR for this case study. Write the ISBAR on the ISBAR worksheet provided. Then, record the ISBAR on Vocaroo,
- Upload the written script for the ISBAR and the vocaroo recording link to the assignment forum.
- The focused documentation and the ISBAR are due by the due date assigned and are graded separately.
Normal ranges for vital signs:
Vital Signs ranges:
Oral temperature: 96.8 – 100.4 F (36 – 38 C)
Heart Rate (Pulse): 60-100 beats per minute
Blood Pressure: 100-140 (systolic – the top number) / 60-80 (diastolic – the bottom number) 100/60 to 140/80 mm Hg
Respirations: 12 – 20 breaths per minute
Pulse Oximetry (oxygen saturation – O2 sat): 95-100%
The following students will complete this case study for the care map:
Group work: Christine, Deeba, Kadijatu
Medical Diagnosis: Intestinal Obstruction
B.T. is a 30 year old male with a history of abdominal surgery 2 weeks ago for appendicitis. B.T. works in computer industry and is single. No other pertinent medical history. Non-smoker.
Nursing Assessment:
B.T. states, “My stomach started hurting really bad, and since I had surgery recently, I knew something was wrong.” Heart rate (HR) 98 regular. Blood pressure (Bp) 110/90. Temp 100.4 F orally. Capillary refill greater than 3 seconds in all extremities. Respiratory rate (RR) 18 breaths per minute. Oxygen saturation (O2 sat) 96%. Holding abdomen and friend brought B.T. to the emergency department. States pain level 9/10, sharp with movement in abdomen and standing, and is “just sort of there all the time.” Abdomen distended and firm on palpation. Bowel sounds diminished in all quadrants. Pain started “sometime yesterday.” States last bowel movement 2 days ago, firm, brown, and no difficulty defecating. Urine sample dark straw color 50 mL. Skin color normal for ethnicity, pale, dry. Mucous membranes dry and pale. States having nausea for the last day and “threw up once this morning.” Oriented to person, place, time, and situation. Grimacing on face.
The nursing assessment above took place on the due date at 1140.
Additional Information for the documentation:
The nurse calls the physician at 1230 requesting labs and for the physician to see the client. After the physician assesses the patient and writes orders, the nurse initiates a peripheral IV in the right forearm IV site, administers antibiotics as ordered, an antipyretic as ordered, and begins an intravenous infusion (IV) of Lactated ringers at 125 mL/hr. At 1330 the client’s vital signs are HR 88, Bp 124/88, temp 99.0F, and oxygen saturation 99% on room air. The client states, “I’m feeling a bit better but tired.”
