This document discusses the ISBAR Plan of Care for Nipun Arora, a 24-year-old male patient with right side chest pain, shortness of breath, and dizziness. It includes identification, background, objective data, problems, planning, nursing interventions, and evaluation.
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ISBAR PLAN OF CARE 1
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Identification Patient name: Nipun AroraAge: 24 Years oldGender: Male Situation: Admission DiagnosisHe reported right side chest pain increasing intensitywithpainscoreof7/10.Healso experiences shortness of breath with dizziness. In order to analyse his condition further his chest X-Ray was taken and arterial gases were obtained Background: HistoryHe had been diagnosed with spontaneous right pneumothorax. He also has a medical history like: he failed to thrive as an infant, pneumonia as a child, work injury (thigh laceration 8/7). Objective dataSubjective data Pulse rate: 119 beats per minute Respiration rate 22 breaths per minute Blood pressure 108/90 GCS 15 Painscore7/10,increasedseverityon inspiration right side chest pain dizziness shortness of breath sharp pain in chest while taking breath Problems (Actual and potential): Breathing issues as Nipun feels sharp pain when he inhale or exhale due to which he is taking small breaths. He feels sharp pain at right side of his chest. When chest drain was conducted, his air leak was lacking or there was forced expiration on a spontaneous breath. Priority of problems: Main priority problem identified was his high pain score. Pain which he was feeling while 2
breathing especially at right side was main priority problem. Planning: Recommendations Expected OutcomeOutcome criteria Pain score should be reduced below 3Painscorelessthan3willhelphimin breathing in a proper manner without feeing anykindofpain.Thiswillalsohelpin measuringeffectivenessofmedications providedtohimandeffectivenessof physiotherapy exercises given to Nipun. Right side chest pain should be removedPatient should not feel any kind of pain while breathingandshouldbeabletobreath normally. Blood pressure should be 120/80Dizziness should not be felt by patient. Not only this, it will also help in reducing pain relate other causes which will help in reducing pain level. Nursing: Interventions InterventionsRationale Physiotherapy can be provided to Nipun Chest pain will be monitored every hour and if any kind of discomfort in chest is observed then it will be reported. Chest drainage procedure will be performed Physiotherapy will help in resolving breathing problem faced by him and will also help in enhancingthisrespiratoryrateandcontrol blood pressure as well Thiswillhelpinevaluatingimprovement within patient’s condition and will also help in identifying changes within current treatment requiredtobebroughtforbringing improvement within their condition. so that proper evaluation of chest pain and any other kind of issue can be done. 3
Pain rating scale will be used continuously to monitor reduction in pain level. Tocheckeffectivenessoftherapiesand medicines provided to the patient. Evaluation: Nursing care plan will be evaluated on the basis of various ways: after 6 hours of nursing interventions, wound management, therapies pain level of patient should be reduced, stabled vital signs of body relaxation should be observed. If pain level is 3 or less then three then patient can be released with provided prescription. 4