ISBAR Plan of Care: Patient UR, Analysis, and Recommendations

This report details an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) plan of care for patient UR, focusing on his diagnosis of prostate cancer and subsequent transurethral resection. The report includes the patient's background, medical history (including type 2 diabetes, hypertension, and a history of malaria), and current situation. It outlines the assessment of the patient's condition, identifies potential problems (such as bleeding and retrograde ejaculation), and prioritizes these issues. The planning section presents expected outcomes, outcome criteria, and nursing interventions, along with their rationales. The evaluation section analyzes the overall care plan and highlights the need for experienced medical professionals. The report emphasizes the importance of preventing excessive bleeding and managing the patient's existing health conditions to ensure the best possible outcome. References are also included.

Tai cam
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Table of Contents
REFERENCES................................................................................................................................4
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ISBAR plan of care
Identification
Patient name
Tai kam
Age/ Date of birth
70 years 31/1/19xx
Gender
male
Situation
The current situation Tai is that he is been diagnosed earlier from bengin prostatic hypertrophy for
prostatic cancer. Also, he is having allergy of malarone (neutropenia). Also, immunisation is weak
due to influenza and pneumococcal vaccine. Now, to cure prostate cancer he has to undergo
transurehial resection of prostate.
Background
Tai was born in Lahn Cam in vang tau in Vietnam. He suffered from malaria at age of 6 years old
since school child. His recovery was impacted for a long time period due to an allergy of
antimalarial medication. This forced him to remain on bed. There is fracture in left ankle when he
met with an accident with motor cycle. Also, there is chronic rhinitis and type 2 diabetes. He is
suffering from hypertension and ischaemic heart disease.
Assessment
Objective data
Patient medical history
Current progress report
Medical plan
Subjective data
Patient background
Report from previous doctors and nurse
Patient relatives
Problems
It has ben identified that there are many problems been faced by tai. As he has gained weight and
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suffering from type 2 diabetes hypertension and heart disease, his lifestyle is sedentary. During
his visit to GP he said he is concerned about prostate cancer. He was diagnosed with bengin
prostatic hypertrophy. In current Tai body did not respond well to medication therapy and now he
is admitted to undergo a transurehial resection of prostate.
Priority of problems
The main problem is as patient is suffering from type 2 diabetes and hypertension thus the might
lead to high bleeding after it. Furthermore, it can lead to rise in retrograde ejaculation. This can
lead to swelling of that area and bruising.
Planning:
Expected outcome
Treating transurehial resection with some
other therapy
Removing growth of tissue with laser
Taking measure to prevent excessive
bleeding
Outcome criteria
Improve in condition
Successful operation
Not so much bleeding.
Nursing intervention
interventions
providing high quality care
Checking diabetes continuously
Reducing hypertension by communication
and interacting with Tai
Rationale
It is done to maintain body condition of Tai
The reason is to maintain level of diabetes
It purpose is to reduce hypertension in tai
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Evaluation
It can be analysed that Tai is suffering from various disease which has already worsen his mental
as well as physical health. Now in order to treat transurehial resection of prostate it required
experience surgeon and medical officer. This will help in analysing medical history of Tai and
suggesting care accordingly. Moreover, it requires a proper and effective care plan to be
developed. Besides, excessive bleeding is to be prevented along with retrograde ejaculation
otherwise it can lead to death of Mr. Tai.
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REFERENCES
Books and journals
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