RN Nursing · Reporting and Handoff Communication · Practice question
Patient's data. Based on the case study, a nurse is calling the doctor concerning the patient. Match each statement with where this information is given according to the ISBAR.
History
0800
A 77 year old male admitted after being involved in a motor vehicle accident (MVA) and sustaining a severe laceration to head, concussion, and multiple severe abrasions.
Current weight: 310lbs
PMH: Type Il Diabetes, Congestive heart failure, Hypertension (HTN) and Rheumatoid arthritis (RA)
Physical Exam: Awake, alert, and orientéd x3. Denies loss of consciousness (LOC), Laceration noted above right eyebrow measuring 10 cm x 1cm x 1,5cm. Bruising noted on the chest with multiple abrasions noted on bilateral knees. Lungs clear bilaterally. Denies chest pain at this time. Heart rate is regular rhythm and rate. Abdomen large, non-distended, bowel sounds present in all 4 quadrants. 2+ lower extremity edema with +1 pedal pulse bilaterally. Social history: Lives alone since wife died 2 years ago. Reports being a good cook and has meals on wheels delivered throughout the week.
Height: 5 feet 10 inches Vital Signs: BP 156/88, Temp 99.0 F R=18 P=90
Laboratory Results
Results Reference Ranges
Prealbumin level 13 mg/dL (15 to 36 mg/dL)
Cholesterol 230 mg/dL (<200 mg/dL)
Fasting glucose 110 mg/dL (70 to 110 mg/dL)
Medication
Prednisone 20mg by mouth every day
Furosemide (Lasix) 20mg by mouth before breakfast
Enalapril (Vasotec) 10 mg by mouth twice a day
Hydrocodone bitartrate 5 mg / acetaminophen 325 mg by mouth every 6 hours prn pain
Answer & explanation
Correct:
The ISBAR framework structures clinical communication as Introduction, Situation, Background, Assessment, and Recommendation. Mapping each row to the correct column: 'My name is Ms. Jones, and I am calling from FGH orthopedics floor about Mr. Blanchard' is the Introduction, identifying who is calling and about whom. 'X was admitted 3 days ago after being involved in a MVA and sustaining a concussion and laceration' provides the Background, summarizing the admission history and reason for hospitalization. 'Patient is complaining of being constipated and states he has not had a bowel movement in 3 days' is the Situation, describing the current clinical problem prompting the call. 'Abd. large with slight tenderness in LLQ. BS present X4. Last dose of hydrocodone was 4 hours ago' represents the Assessment, conveying objective findings and relevant clinical data the provider needs. Finally, 'Fluids and activity are being encouraged. Could we give him something for constipation?' is the Recommendation, proposing a plan and requesting an order. The keyed answer correctly matches these rows to their respective ISBAR components, so no correction is needed.
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