The patient is a 45-year-old male admitted with cough, shortness of breath, congestion, and fever overnight which the physician diagnosed after looking at his x rays of left lower lobe pneumonia. His...

The patient is a 45-year-old male admitted with cough, shortness of breath, congestion, and fever overnight which the physician diagnosed after looking at his x rays of left lower lobe pneumonia. His blood pressure is 132/70, his heart rate 110, respiratory rate 20 on 1L Nasal cannula his oxygen saturation is 94% and he has a temperature of 103.2 F. On assessment he is sweaty and complaining of being hot with no pain and no respiratory distress. The only medical history he has is appendectomy when he was 10 and eczema. He is a full code. He has an allergy to penicillin and gets a rash. As the nurse you are going through the physicians orders and see that he only has IV fluids of Normal Saline ordered at 70ml/hr that are currently infusing through a 20 gauge peripheral IV to the left antecubital, Ceftriaxone 2g IM once daily, and an PRN albuterol nebulizer treatment given by the respiratory therapist. As his nurse you have decided to call the physician based on his assessment and vital signs, fill out the ISBARR tool with the information provided above.

Extracted text: 1. Identity DYourself: Name OPosition OLocation OReceiver: Confirm who you are. O Patient Name: Age Sex Location: Room# 2. Situation State the Purpose "The reason I am calling is...", if urgent say so O Admitting Physician Admitting Diagnosis / Secondary Diagnosis 3. Background Discuss only elements that have recently changed or are pertinent to this patient Admit Date DAnticipated Date of Discharge Surgeries Allergy OCode Status / DNR OPatient /Family Concerns OMedications Given ORecent Intervention / Effecti veness DAbnormal Labs OVital Signs OPain Status I I.V. Wounds / Dressings Orype OLocation O Drainage Systems: Discuss only systems pertinent to this patient ONeurological / Mental Status DLevel of consciousness OLung / Respiratory OLung sounds (rales, rhonchi, wheezes) OShortness of breath, difficulty breathing, orthopnea OCough (productive (description), dry) |Respiratory rate J02 @ OSOB Oximetry Cardiovascular: Liters Heart Rate ORegular Edema ODiet Type Bowel Sounds ONausea OMobility Issues Condition Case Management GI: Abdominal Tenderness Distention OVomiting Musculoskeletal: Last Bowel Movement Fall risk status Hematoma OTemperature Discharge Plan / Issues: Skin: Edema O Patient / Family Education 4. Assessment O Do you have concerns about the patient? OYes If, yes, specify: Discharge planning issues or concerns that need to be addressed O Patient is progressing within normal limits; no complications apparent. No 5. Recommendation Request Care /Issues requiring follow-up O Orders requiring completion / follow-up OPending treatment / tests OIssues / Items left undone that require follow-up ISBAR COMMUNICATION TOOL 00 00 DOO