Limitations in physical activity ability and observation

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Question

R.W. is an 68 year old female admitted to the unit for new onset of limitations in physical activity ability and observation. R.W. has a history of angina. Lives at home with spouse. No history of smoking.

States, "I walk every day in the park." "over the last week, I walked and had to keep taking breaks." "I knew something was wrong." Heart rate (HR) 96 irregular rhythm. Blood pressure 110/80. Temp 98.4 F orally. Oxygen saturation (O2 Sat) 98%. Respiratory rate 20 breaths per minute and regular. Lung sounds clear bilaterally. R.W. on room air. Pitting edema noted in the legs up to the knees bilaterally. R.W. states, "I can't wear my rings," and "my pants are snug around my waist." "I put my feet up at night to get them to not be swollen." Complains of not wanting to eat much (anorexia). States urinating without difficulty about 3-6 times a day of concentrated urine. Urine sample 50 mL dark straw colored. Weight 140 lbs. Patient states, "that's really a lot. I weighed 130 lbs last month in the clinic." R.W. oriented to person, time, place, and situation. Denies cough. Denies pain. Skin warm, moist, intact. Mucous membranes pink and moist.

Write an ISBAR communication worksheet for the above case study

Situation: Briefly describe the current situation. Give a clear, succinct overview of pertinent issues :

Background: Briefly state the pertinent history. What got us to this point?:

Assessment: Summarize the facts and give your best assessment.What is going on? Use your best judgement:

Recommendation: What action are you asking for? What do you want to happen next?

Reference no: EM133843643

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