ISBAR Plan of Care: Patient with Bronchiolitis and Otitis Media

This report presents an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) Plan of Care for a 6-month-old baby, Sophia Tehrani, admitted with bronchiolitis and bilateral otitis media. The plan addresses the patient's respiratory distress, fever, and poor oral intake. The Situation section highlights the patient's symptoms, including a runny nose, fever, and increased work of breathing. The Background details the patient's history, including prematurity and a family history of asthma. The Assessment includes both objective (temperature, heart rate, respiratory rate, SpO2) and subjective (runny nose, irritability) data. The recommendations include administering oxygen, continuing antibiotics for otitis media, and administering paracetamol to manage the fever. The expected outcomes are to reduce fever and improve the patient's breathing. The evaluation will be done daily in order to track the progress of Sophia’s improvement. This plan emphasizes the importance of monitoring vital signs and providing supportive care to improve the patient's condition.

Identification
Please remember to use three identifiers to confirm correct patient
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ISBAR – Plan of Care
ISBAR Plan of Care
Patient name:
UR:
Age/Date of Birth: Gender:
Sophia Tehrani 6 months Female
Situation: Admission Diagnosis
The situation that has been identified is Bronchiolitis
and bilateral otitis media. The patient is RSV negative.
Background: History
Sophia has been breathing quickly and has lots of
discharge from her nose. There was an increase in the
breathing in the last 3 days along with fever, irritability
and poor oral intake.
Assessment
Objective Data Subjective Data
 Temperature – 37 degrees  Runny nose since the last 3 days
HR 130 Poor oral intake
RR 40 Irritability
SpO2 94% on 1litre of oxygen

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ISBAR – Plan of Care
Problems (actual or potential):
Sophia Tehrani, a 6-month-old baby was taken to the hospital following a febrile convulsion at home. She has a poor
oral intake and there was irritability along with runny nose. On examination, it was found that she had a respiratory
wheeze as well as mild subcostal recession. It was also found that she was born pre mature and her mother had a
history of Asthma as a child.
Priority of problems:
Since Sophia is not able to breathe properly, this problem will be dealt with at priority. Next, her oral intake will be
increased so that she gets proper nutrition. A paracetamol will be given in order to bring down the fever and her
oxygen levels will be administered.

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ISBAR – Plan of Care
Planning: Recommendations
Expected Outcome Outcome Criteria
The paracetamol will help in reducing her fever. The body temperature should not exceed 99.5-degree
Fahrenheit.
Help with runny nose. Continue with oral antibiotics.
Nursing Interventions
Interventions Rationale
Admit to the ward So that Sophia can be under observation for her condition
Cardiorespiratory and oxygen saturation
monitoring
In order to ensure that she is able to breathe properly
Administer oxygen In order to maintain oxygen saturation level >93%
Continue Amoxicillin For otitis media
Paracetamol prn In order to help the patient, recover from fever

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ISBAR – Plan of Care
Signature Date
Evaluation:
The effectiveness of the treatment will be done daily in order to track the progress of Sophia’s improvement.
Paracetamol will be given for controlling the fever and also, her sleep routine will be evaluated.