ISBAR Plan of Care: Ectopic Pregnancy, Pain, Anemia, and Nursing Care

This report details an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) plan of care for a patient named Jasmina, who is experiencing pain and bleeding due to an ectopic pregnancy. The report outlines the patient's condition, including her medical history of endometriosis, and recent surgery. The assessment includes objective data such as wound condition and bowel movements, alongside subjective data such as pain levels and concerns about medication. The report identifies key problems like pain, constipation, and anemia. The plan includes recommendations for pain management, fluid intake, and medication adjustments. Nursing interventions include administering pain medications, assisting with mobility, providing the correct antibiotic, and providing emotional support. The evaluation section indicates the patient's progress, including stable vital signs, and the effectiveness of the interventions. The report also includes the patient's response to the prescribed medications.

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ISBAR – Plan of Care
Identification
ISBAR Plan of Care
Patient name:
UR:
Age/Date of Birth: Gender:
Jasmina Tehrani 32 years Female
Situation: Pain in right lower abdomen with small loss of blood per vagina (PV).
Pain and loss of blood increased moderately by evening. Ultrasound scan has confirmed right ectopic
pregnancy. Jasmina had been transferred to the critical care unit, where she had undergone a laparotomy.
Jasmina is having prolonged pain even after the surgery.
Background: Had chicken pox as a child.
Endometriosis, Left wrist fracture, surgical abration of endometriosis, dilatation and curettage for miscarriage,
Iron deficiency and G3P1 (Gravida 3 Parity 1).
Assessment:
Objective Data Subjective data
 Jasmina's wound after the laparotomy is clean
and dry.
 Jasmina’s bowels have opened today.
 As per Jasmina”s condition it is necessary to
remove the PCA and start oral medications for
relieving pain.
 According to her it is very tender to touch and
even hurts while turning around.
 Jasmina feels that she is constipated.
 Jasmina is not very sure about the
effectiveness of the medications.

Problems (actual or potential): Results of the transvaginal ultrasound scan shows that she is having a right ectopic pre
Priority of Problems: After the laparotomy for the ruptured right ectopic, she complains that it is hurting when she moves
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ISBAR – Plan of Care

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ISBAR – Plan of Care
Planning: Recommendations
Expected Outcome Outcome Criteria
To decrease the prolonged pain in Jasminara To give oral painkillers
To increase the hemoglobin limits Provision of blood if required. Iron tonics and folic acids after
the discharge.
To prevent constipation as stated by Jasminara She should be administered with more fluids for softening
her stools.
To prevent nausea and vomiting To change the antibiotic to Cefotaxime other than
tetracycline. Antiemetic for nausea can also be given.
To have a proper abdominal drain The drain should be monitored with an interval of an hour.
Nursing Interventions
Interventions Rationale
Administer pain medications as consulted
by the doctor
Maximum pain control would help Jasmina to recover quickly and
participate in the thoughts of future fertility options.
Assist Jasmina in mobility Assistance in movement would help Jasmina in feeding and toilet
purposes.
Application of correct antibiotic This would prevent the chance of allergic reaction.
To check her haemoglobin limits and her
vital signs
Checking of vital signs would help to avoid complications and would help to
reduce Jasmina’s anaemia
To provide a spiritual and holistic support
to the patient
This would help Jasmina to forget about her loss of pregnancy, as she had
been teary all day after the surgery.

Evaluation:
The patient’s vital signs are found within normal limits.
There are no collections or reddening under the wound.
Jasmina's bowels have opened but she feels she is constipated.
Jasmina had been given with Cefotaxime TDS and antiemetic, which improved her results.
Jasmina’s abdominal drain is scanty and has to be removed.
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ISBAR – Plan of Care
Signature Date