Aala, Jenelyn O.
October 28, 2024
BSN 4B
ISBAR:
I - Identification:
- Patient Name: Mr. Dixon
- Age: 73 years
- Admitted: 2 days ago for a total knee replacement
S - Situation:
- Mr. Dixon has shown a marked increase in bloody drainage from his Jackson Pratt drains.
- The incision site appears red, swollen, and warm.
- IV pain medication is needed every 3-4 hours to manage his pain.
B - Background:
- Admitted for total knee replacement, currently postoperative day 2.
- He’s experiencing nausea and skipped lunch.
- Bowel sounds are reduced.
- He’s avoiding the continuous passive motion (CPM) machine due to pain.
A - Assessment:
- Pain is intense, reported at 6-8 out of 10, temporarily reduced to 2-3 after IV medication.
- The incision site shows possible signs of infection or inflammation (increased drainage,
redness, swelling, warmth).
- His wife, noting his usual resilience, is concerned there may be a problem.
R - Recommendation:
- Closely monitor for infection signs or increased pain.
- Consult with the surgeon before his scheduled evening visit due to increased drainage and
potential infection indicators.
- Reassess pain and nausea management, exploring other pain relief options if CPM refusal
continues.
- Discuss with the physician possible interventions for reduced bowel sounds and nausea.
SCRIPT:
Nurse Jen: Good morning po Ma’am. I'm Jenelyn Aala, endorsing patient Dixon- a 73 years
old, and he had a total knee replacement 2 days ago."
Nurse Ange: "What’s the current situation?"
Nurse Jen: “Today, patient Dixon has experienced a significant increase in bloody discharge
from his Jackson Pratt drains. The incision site appears red, swollen, and feels warm to the
touch.”
Nurse Angge: "How’s his pain management?"
Nurse Jen: "Patient requires IV pain meds every 3 to 4 hours, reducing his pain from 6-8 to 2-3,
but he’s refusing to use the continuous passive motion machine because of pain."
Nurse Ange: "Any other concerns?"
Nurse Jen: Additionally, he's feeling nauseated and declined to eat lunch today. His bowel
sounds are reduced, and his wife is concerned as he usually doesn’t complain.
Nurse Ange: Ah okay so what’s the recommendation?
Nurse Jen: Please monitor the incision closely for signs of infection and vital signs. Reassess
pain management and nausea; consider alternative pain management options if Mr. Dixon
continues to refuse the CPM machine. If he doesn’t improve, we might need to contact the
surgeon sooner. Let’s also encourage him to discuss his pain management options
Nurse Ange: Noted Ma’am. Thank you!
