I INTRODUCE YOURSELF YourName: Your Title: ReasonforBeingThere: S SITUATION Patient: Age: Gender: Height/Weight: Allergies: Code status: Privacy Code: Time: Attending Physician: Patient Chief Complaint: Chief Informant: Family History: History of Current Problem: B BACKGROUND PastMedicalHistory: Current Medications: Social History: A ASSESSMENT VITAL SIGNS: B/P HR RR TEMP SP02 PAIN FALLS RISK Y N IV Site: Accu check: IV Fluids: ISOLATION IsolationPrecautions: Y N Contact Air Droplet HEENT RESPIRATORY CARDIOVASCULAR NEUROLOGICAL GI/GU I & O MUSCULOSKELETAL INTEGUMENTARY LYMPHATIC ENDOCRINE PSYCHOLOGICAL FAMILY – SUPPORT SAFETY LABS/TEST Abnormal: Pending: Ordered R REQUEST/ RECOMMENDATION Handoff report to: From: ©2016 Chamberlain College of Nursing LLC. All rights reserved. Esther Hong RN Report Pt. Condition Ms. Janet A. Lieberman 36 Female 167.6 cm(66 inches) / 59 kg(130 lb) Sulfa 1930 McGuire, Mark Fever, chilly, headache, aches all over body while receiving blood Started Infliximab IV every 8 weeks from 6 months ago, last dose 7 weeks ago. 1000mL 0.9% NaCl IV at 150mL/hr Infusion of 2 units of packed RBCs through IV, stopped at 1.5 unit. Crohn’s disease since age 19, intermittent gastritis. Surgery and Ileostomy in July 2009. Verified with Pt. of any reaction to blood transfusion before. No history of blood transfusion reaction. Pt. came to the ED alone, but Pt’s sister came after she was transfered to the med-surg unit. 103/60 96 22 101.8F/ 38.8 C 92% on 2L O2 headaches, aches all over Left forearm 1000 mL 0.9% NaCl IV at 150 mL/hr Traces of serosanguinous fluid in Pt’s ileostomy bag, Occult blood in fecal sample. Intake: PO: 100mL, IV: 550mL, Blood: 475mL. Total intake: 1125mL Output: Urine: 1250mL, BM: 200mL. Total output: 1450mL RBC: 2.7 million/mm3 Hg: 7g/dL Hct: 21% MCHc: 48 pg/cell Dr. McGuire, Mark Esther Hong (RN) Blood infusion is stopped by RN Esther Hong due to Pt.’s signs of transfusion reaction. Pt is back on 0.9% NaCl IV at 150mL/hr. Pt. requested pain managing medication. Pt. also need antipyretic medication. N/A N/A LABS/TEST RBC: 2.7 million/mm3 Hg: 7g/dL Hct: 21% MCV: 105 mm3 MCHc: 48 pg/cell WBC: 6000/mm3 Platelet count: 162,000/mm3 PTT: 21 seconds PT: 12.2 seconds INR: 0.7 Blood type: AFecal occult blood: positive N/A Please see above

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