A plan of care for the patient Vincent Romero with exacerbation of COPD and symptoms of pneumonia. Includes identification, background, assessment, problems, planning, nursing interventions, and evaluation.
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1 ISBAR – Plan of Care Identification Please remember to use three identifiers to confirm correct patient ISBARPlan of Care Patient name: UR: Age/Date of Birth:Gender: Vincent Romero83 yearsMale Situation:Admission Diagnosis Exacerbation of COPD and the symptoms of pneumonia at the time of admitting the patients. Background: History The patient has been found to have a medical history where the Pertussis and rubella were contracted as child. The patient has been in the habit of smoking for at least 50 years, COPD and emphysema for home exhaustion. Apart form this the patient is also exposed to agricultural chemical development. Assessment Objectiv e DataSubjectiv e Data Neurological Assessment- 4/ 24 Prefers to take shower whenever slight movement is possible Oxygen saturation level was found to be between the 88- 92% on every two liters of Oxygen skin is dry Chest Tightness Mobility of semi fowler Difficulty in breathing
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Problems (actual or potential): The major problem that the patient is encountering is related to the bouts of pneumonia, chronic bronchitis and has also Priority of problems: The first disease that the patient suffers that will be resolved is the pneumonia gouts that the patient is developing and the 3 ISBAR – Plan of Care
4 ISBAR – Plan of Care Planning:Recommendations Expected OutcomeOutcome Criteria ECG test needs to be conducted this morning and levels need to be recorded. The heart rate can help in addressing the problem of chest tightness where the heart related disease can be identified and taken care of. Lower SpO2requires regular oxygen supply through nasals The patient has a difficulty in breathing and this can be resolved through this recommendation. Dietary control where the low sodium diet is the best option When the diet will be in accordance with the vitals the care strategies that have been developed can be met. Due to partial mobility certain exercises can be suggested such as hand movements etc.. The patient needs to keep their body functioning and this care plan strategy will help in energizing and maintaining the flow of blood. The IVC of the patients needs to be changed.The removal of IVC can help in better blood circulation and helps in improving the breathing issues. Nursing Interventions InterventionsRationa le Low sodium Ward Dietary interventionsThis diet will help in providing the necessary nutrition without compromising on the health. Oxygen MaintenanceOxygen needs to be supplied regularly as difficulty in breathing and suffering from chest tightness. Exercises of deep breathing and coughingBoth the exercises will help in addressing the current problem and due to limited mobility as well, this can be addressed. Change in IVCThis will ensure blood circulation is proper and the patient is being supplied with cleaner blood quickly so that energy can be gained
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Evaluation: en developed will address his two major problems i.e. COPD and the pending pneumonia. This is also in accordance with the limit 5 ISBAR – Plan of Care SignatureDate