Question

Make an ISBAR of the ff case scenario. Write how will you communicate with your patient's doctor using ISBAR method.

hand off report at 8Am of Mr George Brainy 18 year old male who was transferred from the ICU yesterday. He was in an MVA 14 days ago. He had some head trauma and subsequent evacuation of a subdural hematoma. Unconsious, unresponsive to painful stimuli, has flaccid extremities.pupils round, sluggish reaction to light, has several abrasions on face and several bruises on shoulders and chest.

VS at 8am- T-97.8F, P- 94, R-24, BP- 124/80, pulse ox-94%

IV of TPN at 80ml/hr via triple lumen right subclavian central line

Fingerstick BG q6H, oral suction prn, NPO, I&O

VS neuro checks q4h

O2 @2-3Lmin NP, seizure prec, HOB 30 degrees at all times

LBM PEG tube clamped

Routine med of Dexamethasone 4mg IVP push q 6H and prn med of Dulcolax-1 supp if no BM

Vital signs at 2pm RR-12, Cheyne Stokes, P- 80, BP- 150/80

Pupils round R●L● non reactive to light.

Skin warm, noted jerky movements of upper extremities

Answer 1

Ans)

Situation:Mr George Brainy 18 year old male who was transferred from the ICU yesterday. He was in an MVA 14 days ago. He had some head trauma and subsequent evacuation of a subdural hematoma.

Background: He had head trauma and subsequent evacuation of a subdural hematoma.

Assessment:

- Unresponsive to painful stimuli, has flaccid extremities, pupils round, sluggish reaction to light, has several abrasions on face and several bruises on shoulders and chest.

- Vital signs at 2pm RR-12, Cheyne Stokes, P- 80, BP- 150/80

Pupils round R●L● non reactive to light.

Skin warm, noted jerky movements of upper extremities

Recommendation: Again to reassess & monitor the patient continuously. Can be decided to shift back the patient to transfer to ICU.