ISBAR Plan of Care: Patient Assessment, Recommendations and Evaluation

This assignment presents an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) plan of care for a patient, Vincent Romero, admitted with exacerbation of COPD and pneumonia. The plan includes a detailed patient assessment, covering both objective and subjective data, such as neurological assessment, oxygen saturation levels, and patient-reported symptoms. The assignment identifies key problems, prioritizes them, and proposes specific recommendations, including ECG tests, oxygen supply, dietary modifications, and exercises. Nursing interventions are outlined, along with their rationales, and the importance of regularly changing the IVC is highlighted. The evaluation section emphasizes the expected outcomes and criteria for success, addressing both the patient's COPD and the developing pneumonia. The plan concludes with a signature and date to indicate the completion of the care plan.

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ISBAR – Plan of Care
Identification
Please remember to use three identifiers to confirm correct patient
ISBAR Plan of Care
Patient name:
UR:
Age/Date of Birth: Gender:
Vincent Romero 83 years Male
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 Data Subjectiv
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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ISBAR – Plan of Care

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
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ISBAR – Plan of Care

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ISBAR – Plan of Care
Planning: Recommendations
Expected Outcome Outcome
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 SpO2 requires 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
Interventions Rationa
le
Low sodium Ward Dietary interventions This diet will help in providing the necessary nutrition without
compromising on the health.
Oxygen Maintenance Oxygen needs to be supplied regularly as difficulty in breathing and
suffering from chest tightness.
Exercises of deep breathing and coughing Both the exercises will help in addressing the current problem and due to
limited mobility as well, this can be addressed.
Change in IVC This will ensure blood circulation is proper and the patient is being
supplied with cleaner blood quickly so that energy can be gained

Evaluation:
en developed will address his two major problems i.e. COPD and the pending pneumonia. This is also in accordance with the limit
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ISBAR – Plan of Care
Signature Date