ISBAR Care Plan for Patient: Healthcare Assessment and Planning

This assignment presents an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) care plan for a patient named Herry Tehrant, who experienced a radial head dislocation and ulna fracture after a fall. The report includes patient information, subjective and objective assessments such as pain levels, swelling, and capillary refill. It outlines the patient's problems, which include the fracture and associated pain, and the priority of the problems. The planning section details recommendations, expected outcomes, and nursing interventions like administering antibiotics, pain management, and monitoring. The report also emphasizes the need for regular neurovascular assessments and post-operative care. The evaluation section highlights the importance of patient self-reliance and awareness regarding their health status. The care plan aims to guide healthcare professionals in managing the patient's condition effectively.

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Identification
Please remember to use three identifiers to confirm correct patient:
ISBAR – Plan of Care
Patient name: Age / Date of Birth: Gender:
Herry Tehrant
10 Years
11/1/xx
Male
Situation: Dislocation of radial head with fracture
of Ulna requiring reduction in theatre
Admission Diagnosis: Breast augmentation
Background:
Fell off balance beam equipment at Paralympics
Radial head dislocation
injury
Decreased sensation
Slightly paleness
History:
Assessment:
Swelling of fingers
Temperature: 37degree
RR: 24
Sluggish capillary refill
Objective Data Subjective Data
  Decreased sensation
 Swelling of fingers  Temperature 37 degree
 Paleness in body  Head pain
  Weight 45 kG

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  Tepid to touch

Problems (actual or potential):
It is stated that the patient Herry Tehrant has fallen down from balance beam machine which is being used in improvin
Priority of problems: One of the main priority of problem is dislocation of head and fractured of Ulna. From medi
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Planning: Recommendations
Expected Outcome Outcome Criteria
Correlation of health status Hygiene skin integrity
Pharmacy ordered Rest in bed up to 2/24
Post observation assistance To make independent
Nursing Interventions
Interventions Rationale
Admit to ward It is stated that the patients have head located and ulna fracture and
for better care it requires proper guidance of nurses Hece admitted in
hospital.
Exercise In the vases of fractures exercise is being recommended in
guidance. It helps patient in moving injured or fractured area
otherwise after sometimes patients have to face problems.
antibiotics One of the main reasons of this intervention is to relive patient
from pain as pain is stated 6 out of 10.
X ray It can help I knowing the extent to which it injured him and
according to the x ray report further medications can be
suggested. It also helped in confirming left ulna and
dislocation of radius.
Paracetamol 6 hourly Patient is suffering from pain and increasing pain cab affect
health and this medicine can help patient in relieving pain.
30 minute post observation
Assistance and
By regular neurovascular and post observation assistance
problems related o back slab care can be improved and also
allow patient in moving head in an effective manner.

Evaluation:
From the above study it has been evaluated that people require becoming self dependent and having awareness of impro
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Signature Date