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ATI Alcohol Disorder ISBAR
ISBAR Document for week 6 ATI alcohol disorder assignment.
Course
Mental-Health Nursing (NR-326)
826 Documents
Students shared 826 documents in this course
University
Chamberlain University
Academic year: 2020/2021
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I
INTRODUCE
YOURSELF
Your Name: Your Title: Reason for Being There:
Patient: J. Moore
Age: 45 y/o
Gender: Male
Height: 175 cm / Weight: 178 lb
Allergies: NKA
Code status: Full
Privacy Code: N/A
Time:
Attending Physician: Dr. Walters
Patient Chief Complaint : MVA
Chief Informant: Family History: History of alcohol abuse by father and grandfather
History of Current Problem:
The patient was involved in a MVA.
Admitted to the ED because of
musculoskeletal, head, and knee
injury. Skin abrasions on the left side
of the body. The blood-alcohol level
was above the legal limit.
S
SITUATION
B
BACKGROUND
Past Medical History:
Broken arm (2x) as a child due to abuse
from his father at a young age.
Current Medications:
Thiamine
Hydrocodone
Ranitidine
Social History:
The patient was working as a construction worker but hasn’t
been able to hold a job in recent months. Spends most of his
time drinking with friends. He recently separated from his wife,
who took his 2 sons away due to his drinking.
A
ASSESSMENT
VITAL SIGNS:
B/P HR RR TEMP SP 02 PAIN
140/88 98 20 37 C 94% 2/
FALLS RISK
Y X N
IV Site: Right Arm Accu check: N/A
IV Fluids:
ISOLATION Isolation Precautions: Y N Contact Air Droplet
HEENT
No erythema, no exudate present. Moist oral and nasal mucosa. PEERAL is intact.
RESPIRATORY
Clear bilaterally in all lobes. Non-labored respirations.
CARDIOVASCULAR
S1 and S2 sounds were heard. Normal sinus rhythm.
NEUROLOGICAL
The patient is alert and oriented x 3, has slurred speech, nystagmus present, labile at this time.
GI/GU
I & O
Occasional nausea with heartburn when overeating.
MUSCULOSKELETAL
ROM intact x4. Pain present in right elbow, shoulder, and arm.
INTEGUMENTARY
Soft tissue and superficial skin abrasions are present from the MVA in the left side of the knee, face and
other areas.
LYMPHATIC
N/A
ENDOCRINE
N/A
PSYCHOLOGICAL
FAMILY - SUPPORT
No family support is present at this time. The patient is separated from his wife, who ended up taking
away his two sons from him.
SAFETY Fall and seizure precautions.
LABS/TEST Abnormal:
Blood alcohol level: 270 mg/dL
Pending: Ordered
X-Ray of left arm and shoulder. CT scan of head and neck. CBC nad drug
screen.
R
REQUEST/
RECOMMENDATION
Alcohol cessation and lifestyle change teachings. Proper diet teaching and medication regiment. Connect patient with support groups such as AA and
community resources. Connect patient with a social worker who can assist in the home health care and financial needs.
Hand off report to: From:
©2016 Cha mberlain College of Nursing LLC. All rights reserved.
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ATI Alcohol Disorder ISBAR
Course: Mental-Health Nursing (NR-326)
826 Documents
Students shared 826 documents in this course
University: Chamberlain University
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I
INTRODUCE
YOURSELF
Your Name: Your Title: Reason for Being There:
Patient: J. Moore
Age: 45 y/o
Gender: Male
Height: 175 cm / Weight: 178 lb
Allergies: NKA
Code status: Full
Privacy Code: N/A
Time:
Attending Physician: Dr. Walters
Patient Chief Complaint: MVA
Chief Informant: Family History: History of alcohol abuse by father and grandfather
History of Current Problem:
The patient was involved in a MVA.
Admitted to the ED because of
musculoskeletal, head, and knee
injury. Skin abrasions on the left side
of the body. The blood-alcohol level
was above the legal limit.
S
SITUATION
B
BACKGROUND
Past Medical History:
Broken arm (2x) as a child due to abuse
from his father at a young age.
Current Medications:
Thiamine
Hydrocodone
Ranitidine
Social History:
The patient was working as a construction worker but hasn’t
been able to hold a job in recent months. Spends most of his
time drinking with friends. He recently separated from his wife,
who took his 2 sons away due to his drinking.
A
ASSESSMENT
VITAL SIGNS:
B/P
HR
RR
TEMP SP02 PAIN
140/88 98 20 37.6 C 94% 2/10
FALLS RISK
Y X N
IV Site: Right Arm
Accu check: N/A
IV Fluids:
ISOLATION
Isolation Precautions:
Y
N
Contact
Air Droplet
HEENT
No erythema, no exudate present. Moist oral and nasal mucosa. PEERAL is intact.
RESPIRATORY
Clear bilaterally in all lobes. Non-labored respirations.
CARDIOVASCULAR
S1 and S2 sounds were heard. Normal sinus rhythm.
NEUROLOGICAL
The patient is alert and oriented x 3, has slurred speech, nystagmus present, labile at this time.
GI/GU
I & O
Occasional nausea with heartburn when overeating.
MUSCULOSKELETAL
ROM intact x4. Pain present in right elbow, shoulder, and arm.
INTEGUMENTARY
Soft tissue and superficial skin abrasions are present from the MVA in the left side of the knee, face and
other areas.
LYMPHATIC
N/A
ENDOCRINE
N/A
PSYCHOLOGICAL
FAMILY - SUPPORT
No family support is present at this time. The patient is separated from his wife, who ended up taking
away his two sons from him.
SAFETY Fall and seizure precautions.
LABS/TEST Abnormal:
Blood alcohol level: 270 mg/dL
Pending: Ordered
X-Ray of left arm and shoulder. CT scan of head and neck. CBC nad drug
screen.
R
REQUEST/
RECOMMENDATION
Alcohol cessation and lifestyle change teachings. Proper diet teaching and medication regiment. Connect patient with support groups such as AA and
community resources. Connect patient with a social worker who can assist in the home health care and financial needs.
Hand off report to:
From:
©2016 Cha mberlain College of Nursing LLC. All rights reserved.