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Mrs F 46 years old female with Crohn disease for past 15 years now she has exacerbation of Crohn disease, diarrhea is decreasing and she has pain in right leg ,pain level is 3 Current vital signs Temperature 37 degree Celsius, BP 140/94 mmhg, Respiration 18 per minute, P rate 76 per minutes, oxygen saturation 97% Complaint of pain in rt leg, no edema, pedal pulse present SUBJECTIVE DATA Married, husband and son supported, Average 5 to 10 loose stools per average, life has become dominated by disease ,anorexia, lactase deficiency ,profound fatigue ,frequent hospitalise for dehydration ,has recuring ,crippling abdomen pain that strikes unexpectedly ,has notice pain in her right leg . OBJECTIVE DATA Temp 38 degree Celsius ,HR 85 per minute 120/74 ,weight 140 lb ,height 5 feet 0 inches Lab test total bilirubin 257 umol/L, serum Ammonia 122 umol/L, Serum potassium 2.5 mmol/L VS q4H,I&O,Weight qAM,Bathroom privileges with assist prn, Right central line inserted,Parenteral nutrition per IV pump @83 mL/hr Lipids 10% (M-W-F) infuse over 12 hours, BG fingerstick q6h, Diet: NPO Routine med: Vit. K 10 mg SC q1weekly Humulin Regular insulin 2 units if BG = 10 – 11 mmol/L Call MD if BG more than 11 mmol/L Mrs. F was taken to x-ray 1 hour ago. On her return to the unit, the IV pump is beeping and you are informed that the machine has been beeping for a long time. You assess the following: TPN not infusing Skin warm, diaphoretic, complains of nervousness and rapid heartbeat VS: T 38 degrees C, P 118, R 26, BP 136/90, Pulse oximetry 96% Follow-up Action Plan: Three hours later, Mrs. F’s family comes to the nursing station to say that Mrs. F is having difficulty breathing. You go into Mrs. F’s room and assess the following: complaints of chest pain, R 36, P134, BP 108/888, pulse oximetry 90%, coughing, dyspnea, anxiousness. Based on this new information what are your next steps? Nursing Assessment As you enter his room you noticed that Mrs. F sitting up in bed. She states she is having a pain in her right leg. could you make a ISBAR in templates
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