sofia tehrani

Identification
Please remember to use three identifiers to confirm correct patient
1
ISBAR – Plan of Care
ISBAR Plan of Care
Patient name:
UR:
Age/Date of Birth: Gender:
Sophia Tehrani 6 months Female
Situation: Admission Diagnosis
The situation that has been identified is Bronchiolitis
and bilateral otitis media. The patient is RSV negative.
Background: History
Sophia has been breathing quickly and has lots of
discharge from her nose. There was an increase in the
breathing in the last 3 days along with fever, irritability
and poor oral intake.
Assessment
Objective Data Subjective Data
 Temperature – 37 degrees  Runny nose since the last 3 days
HR 130 Poor oral intake
RR 40 Irritability
SpO2 94% on 1litre of oxygen

2
ISBAR – Plan of Care
Problems (actual or potential):
Sophia Tehrani, a 6-month-old baby was taken to the hospital following a febrile convulsion at home. She has a poor
oral intake and there was irritability along with runny nose. On examination, it was found that she had a respiratory
wheeze as well as mild subcostal recession. It was also found that she was born pre mature and her mother had a
history of Asthma as a child.
Priority of problems:
Since Sophia is not able to breathe properly, this problem will be dealt with at priority. Next, her oral intake will be
increased so that she gets proper nutrition. A paracetamol will be given in order to bring down the fever and her
oxygen levels will be administered.