ISBAR in Nursing: Patient Assessment and Recommendations

This document discusses the use of ISBAR in nursing for patient assessment and recommendations. It includes a case study of an 18-year-old art student with nose bleeding and provides recommendations for controlling bleeding, speech review, cuff deflation trial, thickened diet, regular dressing of tracheostomy, deep breathing, blood pressure monitoring, and pain management.

Running head: ISBAR IN NURSING
Name of the student:
Name of the university:
Author note
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Part 1
Identification:
An 18 old art student, MR. Sudhakar (family name) also known as zany, presented with nose bleeding
from the nose for one year. His family was presented. He was admitted to the hospital for 1200 hours.
Situation:
He was experiencing severe bleeding from the nose for one year and presented in the hospital due to
the bleeding.
·His previous diagnosis include juvenile nasopharyngeal angiofibroma with intracranial extension with
Status tracheostomy.
Background
· He was experiencing obstruction for 6 months which become severe.
· He is vegetarian and has no habit of smoking and alcohol consumption.
· He has no history of sleep disturbance and has regular bowel bladder habit. No history of allergy was
found.
· He had undergone emergency operation 3 days ago for relieving obstruction with the assistance of
tracheostomy. It involves creating an opening in the neck for placing a tube into the windpipe for
allowing sufficient oxygen delivery to the lungs and reducing obstruction of the airway (Elkbuli et al.
2019).
· His pain status was 7/10.
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· He is currently administrated with medication Panadol along with morphine SC for reducing pain,
salbutamol 5mg NEB prn for reversing airway obstruction and 5ml N/ saline 0.9% for maintaining the
normal blood pressure and dehydration.
·
Assessment
· The current assessment of the patient is monitoring vital signs. Temperature is 37.7°, indicating normal
temperature.
· The heart rate 88bpm, indicating a slightly elevated heart rate as the normal range of the heart rate
include 60 to 100 whereas the ideal heart rate is 50 to 70 (Kaba and Beran 2016).
· The respiratory rate of the patient was 24 indicating slightly elevated respiratory rate since in healthy
individuals, the normal respiratory rate is in between 12 to 20 bpm (Charlton et al. 2016). It may indicate
the presence of tachypnoea.
· The oxygen saturation is 97% which indicate lower in oxygen saturation since Ideal oxygen saturation is
98%, especially for the younger adults (Ceylan et al. 2016).
· His blood pressure was high (140/90) whereas, for healthy individuals, the normal range of blood
pressure is 120/80 (Flynn et al. 2017).
· The pain status of the patient in the pain scale is 1/10, indicating the patient is experiencing severe
pain (Poquet and Lin 2016).
Recommendations:
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· To control the bleeding, the nasal pack is required to provide to the patient. Thomas et al. (2018)
highlighted that it is a placement of an intranasal device which applies constant local pressure to the
nasal septum. It works by giving direct pressure that reduces mucosal irritation and decreases bleeding.
· The speech of the patient is required to review since, in healthy individuals, the speech produces
while air passes over the vocal cords at the back of the throat (Freeman-Sanderson et al. 2016).
However, after tracheostomy, the breathing air passes through the tube rather than the vocal cord.
· Cuff deflation trial is required to begin as cuffed tracheostomy tubes allow secretion clearance and
provide protection from aspiration (Pryor et al. 2016). It will allow patients to manage their own
shallowing and secretions.
· The thickened diet is required to provide to the patient as the liquid can insert into the tracheostomy
tube. The thick diet can prevent this insertion.
· The regular dressing of tracheostomy is required to do for preventing any infection. The dressing
would be done for approximately 8 to 12 weeks.
· The patient would be encouraged to involve in the deep breathing for improving breathing by
clearing the airway and blood flow, increased energy level and reduce inflammation along with improves
digestion (Aravindan et al. 2016). He can be encouraged to involve in the coughing exercise. Coughing
exercise opens up the air passage and improves blood as well as oxygen supply to the lungs.
· The blood pressure of the patient is required to monitor and he can be administrated with beta-
blocker which slows the heart rate and reduce blood pressure (Wiysonge et al. 2017). He can be
administrated with the diet which is devoid of sodium since sodium increases blood pressure in
patient. His pain status is required to assess as his pain status was 1/10. The patient is required to
provide spiritual therapy and music therapy (Ortega et al. 2019). These two therapies can relax patient
and reduce the pain that the patient was experiencing.
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Part 2
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Reference(s)
Aravindan, A., Sinha, R., Priyadarshini, N., Malviya, A. and Hussain, I., 2016. Standardising
markings on paediatric tracheal tubes. Anaesthesia, 71(7), pp.852-853.
Ceylan, B., Khorshid, L., Güneş, Ü.Y. and Zaybak, A., 2016. Evaluation of oxygen saturation
values in different body positions in healthy individuals. Journal of clinical nursing, 25(7-8),
pp.1095-1100.
Charlton, P.H., Bonnici, T., Tarassenko, L., Clifton, D.A., Beale, R. and Watkinson, P.J., 2016. An
assessment of algorithms to estimate respiratory rate from the electrocardiogram and
photoplethysmogram. Physiological measurement, 37(4), p.610.
Elkbuli, A., Narvel, R.I., Spano, P.J., Polcz, V., Casin, A., Hai, S., Boneva, D. and McKenney,
M., 2019. Early versus Late Tracheostomy: Is There an Outcome Difference?. The American
Surgeon, 85(4), pp.370-375.
Flynn, J.T., Kaelber, D.C., Baker-Smith, C.M., Blowey, D., Carroll, A.E., Daniels, S.R., de
Ferranti, S.D., Dionne, J.M., Falkner, B., Flinn, S.K. and Gidding, S.S., 2017. Clinical practice
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Freeman-Sanderson, A., Togher, L., Elkins, M. and Phipps, P., 2016. An intervention to allow
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Kaba, A. and Beran, T.N., 2016. Impact of peer pressure on accuracy of reporting vital signs: An
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Ortega, A., Gauna, F., Munoz, D., Oberreuter, G., Breinbauer, H.A. and Carrasco, L., 2019.
Music Therapy for Pain and Anxiety Management in Nasal Bone Fracture Reduction: Randomized
Controlled Clinical Trial. Otolaryngology–Head and Neck Surgery, p.0194599819856604.
Poquet, N. and Lin, C., 2016. The brief pain inventory (BPI). Journal of physiotherapy, 62(1),
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Pryor, L.N., Ward, E.C., Cornwell, P.L., O’Connor, S.N. and Chapman, M.J., 2016. Clinical
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Thomas, I., Thekkethil, J.S., Kapoor, R.C., Thomas, T. and Thomas, P., 2018. A Novel Technique
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Neck Surgery, 26(1), pp.23-28.
Wiysonge, C.S., Bradley, H.A., Volmink, J., Mayosi, B.M. and Opie, L.H., 2017. Beta‐blockers for
hypertension. Cochrane database of systematic reviews, (1).
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