ISBAR Care Plan: Breast Augmentation and Pyelonephritis Management

This report details an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) care plan for a patient, Amy Jane Millington, focusing on her diagnosis of breast augmentation and suspected acute pyelonephritis. The plan includes a comprehensive assessment of the patient's condition, considering both objective and subjective data such as vital signs, symptoms, and medical history. The report outlines prioritized problems, including the need for antibiotic treatment and management of pain and vomiting. It provides detailed planning, including nursing interventions like ice chips and encouraging oral fluids, along with expected outcomes and outcome criteria. Additionally, the report offers rationales for each intervention and concludes with an evaluation of the care provided and the overall health of the patient. The report emphasizes the importance of patient-specific care and the use of ISBAR framework to ensure effective communication and patient management.

1 ISBAR Care Plan 2015
Identification
Please remember to use three identifiers to confirm correct patient:
ISBAR – Plan of Care
Patient name: Age / Date of Birth: Gender:
Amy Jane Millington
68 Years
1/1/19xx
Female
Situation: Suspected acute pylonephritis
Admission Diagnosis: Breast augmentation
Background:
Sensitive to morphine
Immunalization
Ureteric Relmplant
Small wound breakdown in left breast suture line
Hypertension during pregnancy
Occsional vomiting
abdominal pain,
Urinary incontinence, back injury
History:
Assessment:
CENTRAL NERVOUS SYSTEM: PRN analgesia
Cardiovascular system: OBS stable
GIT (gastrointestinal system): Ward diet
ADL’s (Activities of daily living): dressing
independently
Skin integrity: breast wound healing

2 ISBAR Care Plan 2015
Objective Data Subjective Data
 breast , Swabs taken from breast  Urinalysis
 Occasional vomiting
Abdominal pain
 Sacrum dressing
  BMI-21.0 Kg/m
  Weight 68 kG
  Ureteric reimplant at 4 years

Problems (actual or potential):
It is stated that the patient Amy Jane Millington diagnosed plastic surgery of her breast and face for facelift. After surge
Priority of problems: One of the main priority of problem is Suspected acute pylonephritis and breast augmentation
3 ISBAR Care Plan 2015

4 ISBAR Care Plan 2015
Planning: Recommendations
Expected Outcome Outcome Criteria
Independent with ADL’s Hygiene skin integrity
Vital signs QID Rest in bed up to 2/24
Encourage oral fluids To make independent
IVAb’s Pressure area care
Pharmacy ordered
Nursing Interventions
Interventions Rationale
Ice chips diet It is stated that the patients have abdominal pain as well as
occasional vomiting. Ice chips dieting can help her out in keeping her
healthy and making her feel relief from occasional vomiting.
Swimming She loves swimming and one of the main reasons of
suggesting this and adding it as an activity is reducing weight.
Weight of the patient is 68 Kg. It is over as per the age.
IV antibiotics
One of the main reasons of this intervention is to remove IVC
and resite it.
Intravenous pyelogram It can help her out in solving the main problem which is
discharge from left breast.

Evaluation:
From the above study it has been evaluated that people should take care of themselves and following all interventions g
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Signature Date