Carl Paxton Giles

ISBAR Plan of Care
Identification
Please remember to use three identifiers to confirm correct patient
Patient name: Carl Paxton Giles Age/Date of Birth: 54 years/
19/7/XX
Gender: Male
UR: 719000
Situation: Admission Diagnosis
Carl has been disgnosed with a chest pain and has a medical history of mumps as child.
There seems to be severe central chest pain.
Immunization: Up to date
Allergies: Nil Known
Background: History
Carl has been involved within a serious football injury which has resulted in the gracture in jaw and left femur.
It also has a left knee arthroscopy at the age of 50 years.
Carl has a medical history of type 2 diabetes
Hypercholesterolaemia.
Mumps as child
Assessment
Objective data Subjective data
SPO2 - 95% Sudden central chest pain
The blood glucose level- 4/24 Nauseous
Continuous monitoring of cardiac Sweating
Neurovascular observation

1
ISBAR – Plan of Care

Problems (actual or potential):
Central chest pain
Fracture in law and left femur
Nauseous feeling
Sweating
type 2 diabetes
Hypercholesterolaemia
Priority of problems:
Central chest pain
Nauseous feeling
Sweating
Fracture in law and left femur
Type 2 diabetes
Hypercholesterolaemia