ISBAR_GI_BLEED FINAL EXAM LATEST UPDATE|100% CORRECT SOLUTION

I INTRODUCE YOURSELF YourName: Your Title: Student Nurse Reason forBeing There: Patient Care Patient: Lieberman, Janet A. History of Current Problem: Traces of blood were presentin her ostomy bag. Age:36 S SITUATIO N Gender: Female Height/Weight: 167.6cm (66 inches)/ 59kg (130 ibs) Allergies: Sulfa Code status: Privacy Code: 534689 Time: 1500 Attending Physician: McGuire, Mark Patient Chief Complaint: Abdominal pain , dizziness and blood in stool Chief Informant: Family History: Has a sister that is on her way to the hospital B BACKGRO UND PastMedicalHistory: Chrons diease, Intermitten gastiritis, Iliostomy 6months ago. Current Medications: Remicade q 8weeks last dose 7weeks ago, otc anti inflammatory Morphine 4mg q2hr prn for pain Social History: Drinks alcohol in the evenings to release stress VITAL SIGNS: A ASSESSME NT B/ P HR RR TE MP SP0 2 PAI N 94/.6 95% FALLS RISK Y N IV Site: L arm Accu check: IV Fluids: 1000ml 0.9% sodium chloride at 150ml per hr ISOLATION Isolation Precautions: Y N Contact Ai r Droplet HEENT Alert and orientated X3, normocephalic, EENT- WNL, Mouth and throatpink, dry mouth, nolesions, Uvula rises on phonation. RESPIRATO RY Breathing sounds clear no adventitious sounds CARDIOVAS CULAR HR elevated, S1 and S2 normal NEUROLOGI CAL Exam intact