ISBAR ACTIVITY STUDENT

WORKSHEET
INTRODUCTION
Hi, this is Marina Di Pede. I am a registered nurse (RN) on the patient
Your name, position (RN), unit you anesthesia care unit (PACU) calling to give report on D. R. who is
are working on going into room 214.

SITUATION
I am the primary nurse for D. R., a 60 year old male who came into
Patient’s name, age, specific reason for the visit the hospital to receive a Whipple surgery as per a diagnosis of
pancreatic cancer.

BACKGROUND
D. R. began surgery at 0800h today and came into my care at 1400h.
Patient’s primary diagnosis, date of D. R. has a history of anxiety, depression, G. E. R. D., hypertension,
admission, current orders for patient and pancreatic cancer. D. R. pre-operatively was very active, ate a
healthy diet, and drank plenty of fluids. Pre-operatively, this patient
was taking amlodipine 10mg once daily and venlafaxine 225mg once
daily. As per pre-operative data, his blood pressure was 147/80 and
his heart rate was 64 beats per minute. He was alert and oriented. D.
R. currently has dimenhydrinate IV 25mg q8hr PRN, hydromorphone
1mg IV q2hr PRN. He currently has an epidural infusing at 5mL/hr,
with a bolus of 2mg and a lockout of 20 minutes. He has not received
any PRN medication during his time with me.
ASSESSMENT
On arrival, the patient was alert and oriented but lethargic. D. R.
Current pertinent assessment data using head verbalized that on assessment, his sensation block was between T7-L4
to toe approach, pertinent diagnostics, vital bilaterally. The patient was able to move his ankles and bend his
knees. I recognized a foley catheter in place. He had Normal Saline
signs
infusing at 50mL/hr, a nasogastric tube in the right nare to low-
intermittent suction, draining green, dark, thick gastric fluids, and a
Jackson-pratt drain to his right lower quadrant draining sanguineous
fluid. I noticed a midline incision with a dressing 50% saturated in
sanguineous fluid. Bowel sounds were hypoactive. Skin appropriate
to ethnicity, dry, and room temperature. There was no edema noted to
any extremities. Vital signs were stable, and the patient was in no
pain. His chest was clear, and bowel sounds hyperactive.
I was told in report that the patient lost 3L of blood throughout
surgery.
Two hours following his surgery, so at 1600h., D. R. was oriented to
person and disoriented to time, place, and situation, and was
extremely fatigued, only responding to pain sensation. His vital signs
were as follows: BP 82/45, HR 110bpm regular, temperature 37.4
degrees Celsius orally, respiratory rate of 22, and an oxygen
saturation of 95% on 2L O2 via nasal prongs. He was diaphoretic and
pale with dry mucous membranes. I noticed his foley catheter had
only put out 10mL of dark, amber urine while his Jackson-pratt drain
emptied a total of 300mL of sanguineous fluid. The nasogastric tube
drained 500mL of green, dark, thick gastric fluids since OR. He was
complaining of some leg cramps. His blood work displayed
hypernatremia, hypokalemia, and decreased creatinine. His chest was
had crackles bilaterally, bowel sounds hyperactive, and heart rate
regular but tachycardic.
I requested from the surgeon that he receive a bolus. The surgeon
 ordered D. R. a 2L Normal Saline bolus, which was provided at
1620h. The maintenance IV changed to Normal Saline with 20mEq
KCL infusing at 100mL an hour.
Currently, at 1730h, D. R. is alert and oriented. His foley output has
increased while his Jackson-pratt and nasogastric output has
decreased. He remains pale but is no longer diaphoretic. His vital
signs are currently as follows: BP 114/75, HR 76bpm regular,
temperature 36.9 degrees Celsius orally, respiratory rate of 18, and an
oxygen saturation of 99% on 2L O2 via nasal prongs for comfort. His
leg cramps have decreased and chest is now clear. He is stable and to
be admitted onto the inpatient unit.
RECOMMENDATION
I recommend monitoring vital signs frequently to ensure they remain
Any orders or recommendations you may stable. Place some attention to the repeat bloodwork that has been
have for this patient drawn as results are pending. D. R. remains NPO with an NG to low
intermittent suction, so I recommend monitoring the colour and
amount of output. I recommend also monitoring foley catheter and
Jackson-pratt output and colour. This way we can ensure he is
receiving plenty of fluids and maintaining stable electrolyte levels.
 References

Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Barry, M. A., Lok, J., Tyerman, J., & Goldsworthy, S.

(Eds.). (2019). Medical -Surgical Nursing in Canada: Assessment and Management of Clinical Problems (4th

ed.). Elsevier Canada.