Safe Transfer of Patient Information

The assignment provides a comprehensive example of an ISBAR (Identify, Situation, Background, Assessment, and Recommendation) handover script for nurses. The script is designed to facilitate safe communication between healthcare professionals regarding the situation of a patient named Kate, who has undergone recent surgery and is experiencing low blood glucose and pressure levels. The script includes identification, situational, background, assessment, and recommendation sections, providing a clear and structured approach to sharing critical information.

Nursing Case Study

Table of Contents
Outline of the case.......................................................................................................................1
Justification to clinical nursing decisions....................................................................................2
ISBAR handover script................................................................................................................4
REFERENCES................................................................................................................................5

Outline of the case
The patient named Kate Ham, who is 79 years old, has visited to the surgery ward of the
hospital. She weigh’s 75 kgs. with a height of 153 cm which comes under the category of being
overweight.
Clinical condition: She has undergone under Right Total Knee Replacement (RTKR) surgery.
Total blood loss during intra operative practice is 200 ml and Intravenous Therapy (IVT) up to
1200 ml.
Medical history: She also has a history of Non-Insulin Dependent Diabetes Mellitus (NIDDM).
Further, she is also asthma / smoker 50/day.
Current situation and sign and symptoms: The case further states that the patient appears to be
restless, pale and grimacing in pain with her eyes shut. The dressing of her wound is dry and
Patient Controlled Analgesia (PCA) has not been brought into use since past hours. She has
stated that the pain in her knee scores 5 / 10 and feeling lightheaded as well. She has been
allowed light diet by the doctor. However, she does not feel like eating anything and sense
constant nausea.
Vital signs: Current BP measures tends to be 105 / 56, Heart Rate (HR) 118, Respiratory rate is
20, peripheral capillary oxygen saturation (SpO2) is 92%, Blood Glucose Level (BGL) is -3.5
and periphery capillary refill is 3 seconds plus pale cool digits. Other observation criteria are
being found stable in her.
Ongoing medications: Seretide (250/25) which is used to clear out the ways, when patient is
suffering from Asthma. Metformin which is given to control the level of glucose in the blood,
which is diabetes.
The nurse is accompanying the patient after Kate has gone through post-operative period
of 4 hours in RTKR surgery. The immediate nursing actions can be stated that the patient in
undergoing low Blood pressure due to which she is constantly feeling nauseated and light
headed. Moreover, her blood glucose level is also at a decreasing state, that is -3.5. hence, the
initial treatment to be given by the nurse will have high dependence on these two aspects of her
current health (Burns and Grove, 2012). Since, she has undergone knee replacement surgery, it is
important to emphasize on blood glucose level and bring back to normal. Moreover, her low
blood pressure can be the result of anaesthesia being given to her during her surgical operation.
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Medication an be given through IV by the nurse to bring blood pressure to the normal state
(Rasheed, 2013). One of the important aspects that needs to be considered by the team of nurses
is to enhance the quality of patients in which he or she is surviving. For instance, taking care of
the cleanliness of the environment, providing healthy diet to the patient and providing
medications on time can help in enhancing the culture and practices of a nurses adopted by them
at the workplace. These are the important aspect t6o enhance the safety of patients as immunity
of the patient is already low is she is going through certain disease. In that case, chances of
getting attracted towards the other disease is bit higher. Hence, in order to reduce the prevalence
of new disease focussing upon best medical and nursing practices can help in improving the
quality iof living of the patient in the hospital.
Justification to clinical nursing decisions
Nurses opt for the interventions and medical decisions that calm down the patient for
certain period of time and can also help in reducing the complication of the situation. In the
present case scenario of Kate, who has recently undergone RTKR surgery 4 hours earlier, have
been facing certain medical issue which may not be good for her current state. The state of Kate
and nursing interventions performed on her can be analysed through DETECT format which is
discussed as under:
Detect: The wound of the patient is dry and no ooze have been analysed which states that
her knee is at normal state and there is no after surgery complications that are involved in it.
Further, her blood pressure level is also low, that is 105 / 56. The heart rate of the patient is also
high as per her age which must have been 86 – 100 at the beginner’s stage (Holloway and
Galvin, 2016). The patient also has a history of Non-Insulin Dependent Diabetes Mellitus where
she is under the medication of metformin to control her glucose level in her blood. It states that
she has to bring back her glucose level to the normal. Moreover, the patient is not facing issues
with the pain and the level of pain is just 5/10. Hence, in that case, main interventions that are
required for the patient is controlling of blood glucose level and Blood pressure level (Munhall,
2012). Further, hospital is the place where majority of the disease exist and transmission of it
from one patient to another is also easy. Hence, detection of the issue in case of Kate is
important.
Evaluation of findings: Evaluating the findings being stated by the nurse., the common
risk factors that are involved in the condition of patient have high dependence on her age and
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obesity level. When blood sugar level decreases, the level of energy in the cells is starved. At the
initial stage, the reflected symptoms may be minor, but, it can also lead to serious complications.
The state is also known as insulin shock. It can be the result of any complication of another
disease and disorder as well (Polit and Beck, 2014). Since, the patient has recently gone through
a surgery, the decrease in level of glucose can be the symptomatic results of anaesthesia being
given to her during the surgery. There are various risk factors, one of them is increased risk of
bacterial infection in the body. Elevated state of blood glucose can help in reducing the ability of
blood infection and increases the ability of the body to fight with leukocytes. Further, low blood
glucose level can also lead to slow healing of the wounds. Presence of Neutrophils can greatly
show healing to the skin and soft tissues. Other risk factors involve, fatigue, light headedness,
chronic constipation or diarrhoea and irritability (Speziale, Streubert and Carpenter, 2014).
The normal rage of blood pressure for any individual is 120 / 80 (Scott and Spouse, 2013).
However, in case of Kate, the current rage detected to be 105 / 56. It shows that the patient is
facing the state of low blood pressure. One of the main cause of low blood pressure in the patient
is in take of metformin even if the blood glucose level in the body is low in comparison to the
normal (Watson, 2014). Eliminating the intake of Metformin can help the nurse in dealing with
the issue. There are various risk factors that are involved in case of Low Blood Pressure. At a
minor stage, it can result in dizziness, weakness, risk of injury from falling and fainting as well.
However, in extreme cases, low blood pressure can also lead to damage of heart and brain
(Glasby, 2012).
Treatment: In order to treat low blood glucose level, the nurse have opted for glucose IV.
It will help in maintaining the level of glucose which will further give comfort to the patient.
Moreover, in order to treat low blood pressure level, the nurse have opted for eliminating the
next 4 doses of metformin which is responsible for controlling blood glucose level in the body.
Several other medications can also be used by the health care professionals to treat the issue. It
includes, Glimepiride, Glipizide, Glibenclamide, etc (Liveng, 2014). It is important that the nurses
who are handling Kate are well trained so as to deal with the prevailing situation. In that case,
increased opportunities for the nurses to learn and understand the issue can help in increasing the
quality of living of the patient during her hospital reside.
Escalation of concerns: The concern can be escalated to the health care professionals if
the intervention of nurses has not brought any improvement in the health of Kate. The nurse is
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advised stay with the patient so that the condition can be constantly analysed and communicated
to the health care professionals at constant intervals (ISBAR - Identify, Situation, Background,
Assessment and Recommendation, 2017). Tailor made quality of services are required based
upon the requirements of the patient. Since, Kate is suffering from low blood pressure. Hence, in
that case the nurse be aware regarding the medications that needs to be given to her in case of
emergency.
Communication: While communicating the condition to the health care professional it is
important for the nurse to follow the guidelines of communication mentioned in ISBAR format.
It is the combination of Identification, Situation, Background, Assessment and Recommendation.
Documentation of clinical records of Kate so that doctor is known to the medical history of the
patient in a detailed manner. The document also includes expected treatment and period of
review of Kate as well.
Teams: Teams are formed in such a manner that the activities can be coordinated and
communicated clearly to the higher authorities. Assigning the role of practice and adopting
strategies can help in better dealing with the current situation of Kate. It is the responsibility of
the team leader to enhance the functions of the team. The purpose is to communicate the goals
and prepare strategies that can easily be understood by the team and can be followed in case of
Kate. Adopting technological training and proving the same to the nurses can help in fulfilling
the objectives of patients in the hospital.
ISBAR handover script
ISBAR stands for Identify, Situation, Background, Assessment and Recommendation
which is involved in transferring critical information safely to the seniors and the other health
care professionals, regarding situation of Kate. In that case following script can be transferred to
the team in the following manner:
Identification: Kate is 79 years old female, weighing 75 kgs.
Situation: Recently undergone RTKR surgery 4 hours earlier and now facing low blood
glucose level and low blood pressure level. Currently Blood pressure level is 105 / 56 and blood
glucose level are -3.5 (McSherry and Pearce, 2013).
Background: She is having a medical history of Non-Insulin Dependent Diabetes Mellitus
(NIDDM) also have asthma / smoker for which she is involved in undergoing continuous
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treatment. She is involved in continuous consumption of Metformin and Seretide in order to
control the level of blood glucose level and Asthma.
Assessment: Nurses have stated that reduced blood glucose level and blood pressure level
may be due to anaesthesia been given to her during her operation. It can be stated that the
condition will improve in next 24 hours as and when the impact of anaesthesia will reduce from
the body.
Recommendations: In order to control the current situation of Kate, Metformin will be
discontinued for the next 4 dosages. Moreover, to bring the blood pressure at the normal state,
glucose IV will be transmitted to the body of Kate so that enough glucose is available in her
body for her basic functions. It will also help in coping up with the situation of nausea and light
head.
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REFERENCES
Books and Journals
Burns, N., & Grove, S. K. (2012). Understanding Nursing Research-eBook: Building an
Evidence-Based Practice. Elsevier Health Sciences.
Glasby, J., (2012). Understanding Health and Social Care. The Policy Press.
Holloway, I., & Galvin, K. (2016). Qualitative research in nursing and healthcare. John Wiley
& Sons.
Liveng, A., (2014). Learning and recognition in health and care work: an inter-subjective
perspective. Journal of Workplace Learning. 22(1/2). pp.41–52.
McSherry R. & Pearce, P., (2013). Clinical Governance: A Guide to Implementation for
Healthcare Professionals. John Wiley & Sons.
Munhall, P. L. (2012). Nursing research. Jones & Bartlett Learning.
Polit, D. F., & Beck, C. T. (2014). Essentials of nursing research: Appraising evidence for
nursing practice. Lippincott Williams & Wilkins.
Rasheed, E., (2013). BTEC First Health and Social Care Level 2 Assessment Guide: Unit 8
Individual Rights in Health and Social Care. Hachette UK.
Scott, L. & Spouse, J., (2013). Practice Based Learning in Nursing, Health and Social Care:
Mentorship, Facilitation and Supervision. John Wiley & Sons.
Speziale, H. S., Streubert, H. J., & Carpenter, D. R. (2014). Qualitative research in nursing:
Advancing the humanistic imperative. Lippincott Williams & Wilkins.
Watson, J. (2014). Nursing. University Press of Colorado.
Online
ISBAR - Identify, Situation, Background, Assessment and Recommendation. 2017. [Online].
Available through <
http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/
clinical+resources/clinical+topics/clinical+handover/isbar+-
+identify+situation+background+assessment+and+recommendation>
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