Case Study: ISBAR Plan of Care for Chest Pain and Patient Management

This case study presents an ISBAR (Identification, Situation, Background, Assessment, Recommendation) plan of care for a 54-year-old male patient, Carl Paxton Giles, diagnosed with chest pain and a medical history including type 2 diabetes and hypercholesterolemia. The plan prioritizes addressing the patient's central chest pain, nausea, and sweating, followed by managing his fracture in law and left femur, type 2 diabetes, and hypercholesterolemia. The planning phase includes recommendations for diet, medical assessment, skin integrity, and pain management, with interventions ranging from non-pharmacological therapies to medication and IV therapy. The evaluation emphasizes the importance of diet, medication, and various treatments to improve health outcomes, highlighting the role of pain assessment in identifying the cause and suitable interventions.

ISBAR Plan of Care
Identification
Please remember to use three identifiers to confirm correct patient
Patient name: Carl Paxton Giles Age/Date of Birth: 54 years/
19/7/XX
Gender: Male
UR: 719000
Situation: Admission Diagnosis
Carl has been disgnosed with a chest pain and has a medical history of mumps as child.
There seems to be severe central chest pain.
Immunization: Up to date
Allergies: Nil Known
Background: History
Carl has been involved within a serious football injury which has resulted in the gracture in jaw and left femur.
It also has a left knee arthroscopy at the age of 50 years.
Carl has a medical history of type 2 diabetes
Hypercholesterolaemia.
Mumps as child
Assessment
Objective data Subjective data
SPO2 - 95% Sudden central chest pain
The blood glucose level- 4/24 Nauseous
Continuous monitoring of cardiac Sweating
Neurovascular observation

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ISBAR – Plan of Care

Problems (actual or potential):
Central chest pain
Fracture in law and left femur
Nauseous feeling
Sweating
type 2 diabetes
Hypercholesterolaemia
Priority of problems:
Central chest pain
Nauseous feeling
Sweating
Fracture in law and left femur
Type 2 diabetes
Hypercholesterolaemia

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ISBAR – Plan of Care

Planning: Recommendations
Expected Outcome Outcome Criteria
It helps in improving the health results and outcomes. Appropriate level of diet which is fat free, salt free with
appropriate ward diet.
Medical assessment Skin and hygiene integrity
Pan assessment Pain has been managed effectively
Effective breathing pattern Breathing rate must be normal
Nursing Interventions
Interventions Rationale
Non- Pharmacological intervention Therapies like massage, relaxation techniques, physical
therapy.
Medication intervention Asprin, Paracetamol, cholecalciferol, Glipizide, Metformin
and Simvastatin.
Chest pain management It helps in managing the central chest pain with Anglogram.
IV theraphy It helps in managing the chest pain among the patient.
Vital signs monitoring It helps in assessing the key components to control the
central chest pain. It helps in monitoring oxygen saturation.

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ISBAR – Plan of Care

Evaluation:
Chest pain can be effectively treated using appropriate diet plan, medication, pharmacological and non- pharmacological treatment, IV
theraphy, to improve the health results and outcomes. Assessment of the pain helps in finding out the key likely cause related with the
chest pain and finding the best suitable intervention for the patient.
Signature______________________________________ Date________________
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ISBAR – Plan of Care