Case Study: ISBAR Plan of Care for Mary Young, Healthcare Analysis

This report presents a detailed case study of Mary Young, a 71-year-old female admitted with an ischemic stroke. The analysis follows the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) framework. The situation involves Mary's collapse and diagnosis. Her background includes a history of allergies, chronic otitis media, osteoporosis, atherosclerosis, atrial fibrillation, and uncontrolled diabetes. The assessment covers objective and subjective data related to her central nervous, cardiovascular, neurovascular, and gastrointestinal systems, including the use of a PEG tube for nutrition. The report identifies actual and potential problems, prioritizes them, and recommends interventions such as fluid balance charts, mobility assistance, and cardiac monitoring. Nursing interventions include diabetes management, promoting understanding of osteoporosis, and dietary changes. The expected outcome is improved health, and evaluation focuses on Mary's progress and adherence to the care plan. This report also includes the evaluation of the nursing interventions and the expected outcomes, providing a comprehensive overview of Mary Young's care plan and the factors contributing to her recovery.

Mary young Case study

Identification
Please remember to use three identifiers to confirm correct patient
Patient name:
UR:
Age/date of birth Gender:
Mary Young
201 407
71
03/07/19XX
Female

Situation: Admission Diagnosis
Mary Young is having Ischemic stroke 5/7 ago, Mary is collapsed at home and was also found
on the floor by her grandson.
Background: History
Mary is a female who live with her family in Horizon, her daughter Merrilyn is very supportive
and she also come to visit her mother every day and quite stressed related to her mother. She has
an allergic problem and Chronic otitts media as a child, osteoporosis. Doctor also find new
disease i.e. Atherosclerosis and Atrial Fibrillation and two type of diabetes which are
uncontrolled.
Assessment:
Objective data Subjective data
CNS: central Nervous System Pains, alert and oriented, aphasia i.e. trouble
in speaking
Cardio vascular system Helps in observation to determine the
situation is stable
Neurovascular system R side hemiparesis i.e. weakness
Gastrointestinal system At that time Percutaneous Endoscopic
gastronomy tube is provided that helps to
provide nutrition and person who face
difficulty in swallowing.
Mobility As Mary requires help with mobilizing and
the Physiotherapist also arrange the mobility
aid for Mary i.e. her Daughter
Discharge Planning Awaiting placement at the Horizon care
facility

Problem (Actual or potential)
As per the past medical history, below mention is the list of issue which Mary have
 Chronic Otitis media as a child- has led to hearing deficits
 Tonsillectomy as a child
 Measles at 8 years
 Osteoporosis- poorly managed
 Cardiovascular disease (atherosclerosis)- diagnosed on admission
 Diabetes mellitus Type 2- diagnosed on admission
 Atrial Fibrillation- diagnosed on admission
Current
 Diagnosis: Ischaemic stroke 5/7
 Allergies: Penicillin i.e. rash
 Immunisations: Pneumococcal and influenza vaccination due, otherwise UTD
Priority of problem:
As Mary face issue of lots of problem because of his old age and all the problem are consider as
a priority for her.
Planning recommendations
Expected outcome Outcome criteria
She have to provide fluid balance chart It helps to live because she face issue of not
eating food.
Assistance require for mobility and hygiene
and prefer her daughter
She is very hygienic person and it will help to
be fresh.
Cardiac Monitoring for new AF diagnosis Help to control her heart rate.
Nursing Intervention

Intervention Rationale
Nurses should take care of
proper food and make timely
insulin. Provide intensive
treatment
This will help to manage the problem of Diabetes. Also,
through intensive treatment, three to four insulin are injected
per day and weekly contact should be done.
Promoting Understanding of
Osteoporosis and relieving pain
In this, Mary rest in the bed in a supine and side lying
position several a times in order to encourage good posture
and also, patient teaching focus on the factors influencing the
development of Osteoporosis.
Proper dietary changes This will help to sort out the problem of swallowing and
eating food and as Mary face issue related to eating food and
that is why, PEB is prescribe in order to swallowing the food
in better manner.
Evaluation
From the above, it is evaluated that through nursing intervention and properly medication, Mary
Young will easily overcome form the problem and this will assist to lead their life in better
manner. Also, with the help of her family, she will be easily cured and her daughter should make
sure that they comply with all the instruction given by doctor.