Identification
The patient came in with nausea, vomiting and dehydration. He has a history of colon cancer and has been undergoing chemotherapy treatments for the past few days. However, he has not been able to hold down any food for the past three days. The nurse on duty started the patient on D5LR at 1:25 through a 20-gauge needle placed in his right arm. The patient was also given 8mg of Zofran about thirty minutes before the start of his assessment by the nurse at the station. Identification is important because it aids in understanding the situation and the patient (Moi et al., 2019). It is vital to identify both.
Situation
Patient came in with nausea and vomiting, so they checked the abdomen, lungs, and heart. The patient has reported having watery diarrhea and vomiting numerous times during the day. The patient also reports feeling cold in the room and extreme stomach discomfort. The patient was a former smoker who quit about two years ago. The nurse on the station is coming in to complete his admission database. She is seen to be rubbing her hands with alcohol, meaning she has washed her hands. The nurse identifies herself and states her purpose in the room. She then asks for the patient’s name and date of birth. She diffuses the situation about the completion of the admission report and asks who the other individual in the room is. She then shakes his hand and calls upon him to help her where he can.
Background
The patient has colon cancer and is undergoing chemotherapy and will undergo surgery after the chemotherapy is completed. The chemotherapy is meant to be performed for a period of at least six months. The patient reports being a former smoker who quit two years ago.
Assessment
The nurse checks the patient’s temperature and it is revealed to be within the normal range as it reads 98.5 degrees. The nurse checks the abdomen, lungs, and heart. The nurse uses the stethoscope to listen to the abdomen to identify if there are any noises. The nurse presses lightly and deeply at various points in the stomach to determine the presence of pain in various areas. After pressing each area, the nurse asks the patient where they feel pain and eventually the patient presents pain on the left lower section and the right lower sections of the stomach. The patient reports that the tumor is on that part of the stomach. The nurse asks the patient if they have trouble urinating and inquires on the color of the urine. The nurse sits up the patient and checks his lungs by asking the patient to take some breaths in and out.
The nurse also asks for the son’s help in getting the patient to sit up so they can check the back of the lungs. The nurse also checks the patient’s pupils for their reaction to light and also how the eyes react to accommodation. The nurse checks the patient’s skin for any rashes or conditions. The nurse feels the pulse of the patient on both hands and feet to determine if the pulse is equal and strong on both sides. The nurse also presses on the toe to see how fast blood rushes back to the toe and also feels the warmth in the patient’s legs to determine if their circulation is adequate.
Recommendations
The nurse recommends the addition of fluids for the patient as they appear to be dehydrated. The nurse also recommends some rest to the patient as they continue to recover from their treatment.
Reference
Moi, E. B., Söderhamn, U., Marthinsen, G. N., & Flateland, S. (2019). The ISBAR tool leads to conscious, structured communication by healthcare personnel. Sykepleien Forskning, 14, 74699.