vSim ISBAR Activity Student WorksheetIntroduction(Your name, position (RN), unit you are working on)Mary Frometa (RN)Emergency Department SituationPatient’s name, age, specific reason for visitStan Checketts , 52 years old male,Reason for visit : Rule out preoperative bowel obstruction BackgroundPatient’s primary diagnosis, date of admission, current orders of patientAdm DX: Rule out preoperative Bowel Obstruction Adm on 4/14/2020Current Orders:Start IV and give normal saline fluid bolus 500 mL over 30 minutes. Oxygen to maintain SpO2 greater than 92%ECG monitoring Diet NPOInsert nasogastric tube to low intermittent suction Labs: CBC , Chemistry profile , Abdominal X-ray Meds Buprenorphine 0.3 mg slow IV push every 6-hour PRN pain Ondansetron 4-8 mg IV push every 6 hours PRN nausea AssessmentCurrent pertinent assessment data using head to toe approach, pertinent diagnostics, vital signsVital Signs Heart rate: 129 Blood pressure: 108/78 mm Hg. Respiration: 29. SpO2: 90%. Temp: 99 F (37 C)There is decreased skin turgor. His skin is quite cold. Patient is breathing at 28 breaths per minute. The chest is moving normally on both sides. The breath sounds are normal. There were only normal heart sounds noted. Hyperactive sounds from the abdomen noted. The IV site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. Patientstated a pain level of 4 that has been present for a few days.