ISBAR Plan of Care for Nipun Arora: Case Study Analysis and Plan

This assignment presents an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) plan of care for a case study involving a 24-year-old male patient, Nipun Arora, diagnosed with spontaneous right pneumothorax. The plan details the patient's condition, including reported right-side chest pain, shortness of breath, and relevant medical history. It outlines objective and subjective data, identifies actual and potential problems like breathing issues and pain, and prioritizes high pain scores. The planning section recommends interventions such as physiotherapy and pain monitoring, with expected outcomes like pain reduction and improved blood pressure. Nursing interventions and their rationales are provided, alongside a clear evaluation strategy based on pain levels and vital signs. This comprehensive ISBAR plan offers a detailed approach to managing Nipun's care, considering ethical, legal, and cultural considerations, along with the use of assessment tools and shift planning.

ISBAR PLAN OF CARE
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Identification
Patient name: Nipun Arora Age: 24 Years old Gender: Male
Situation: Admission Diagnosis He reported right side chest pain increasing
intensity with pain score of 7/10. He also
experiences shortness of breath with dizziness.
In order to analyse his condition further his
chest X-Ray was taken and arterial gases were
obtained
Background: History He had been diagnosed with spontaneous right
pneumothorax. He also has a medical history
like: he failed to thrive as an infant, pneumonia
as a child, work injury (thigh laceration 8/7).
Objective data Subjective data
Pulse rate: 119 beats per minute
Respiration rate 22 breaths per minute
Blood pressure 108/90
GCS 15
Pain score 7/10, increased severity on
inspiration
right side chest pain
dizziness
shortness of breath
sharp pain in chest while taking breath
Problems (Actual and potential):
Breathing issues as Nipun feels sharp pain when he inhale or exhale due to which he is taking
small breaths. He feels sharp pain at right side of his chest. When chest drain was conducted, his
air leak was lacking or there was forced expiration on a spontaneous breath.
Priority of problems:
Main priority problem identified was his high pain score. Pain which he was feeling while
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breathing especially at right side was main priority problem.
Planning: Recommendations
Expected Outcome Outcome criteria
Pain score should be reduced below 3 Pain score less than 3 will help him in
breathing in a proper manner without feeing
any kind of pain. This will also help in
measuring effectiveness of medications
provided to him and effectiveness of
physiotherapy exercises given to Nipun.
Right side chest pain should be removed Patient should not feel any kind of pain while
breathing and should be able to breath
normally.
Blood pressure should be 120/80 Dizziness should not be felt by patient. Not
only this, it will also help in reducing pain
relate other causes which will help in reducing
pain level.
Nursing: Interventions
Interventions Rationale
Physiotherapy can be provided to Nipun
Chest pain will be monitored every hour and if
any kind of discomfort in chest is observed
then it will be reported.
Chest drainage procedure will be performed
Physiotherapy will help in resolving breathing
problem faced by him and will also help in
enhancing this respiratory rate and control
blood pressure as well
This will help in evaluating improvement
within patient’s condition and will also help in
identifying changes within current treatment
required to be brought for bringing
improvement within their condition.
so that proper evaluation of chest pain and any
other kind of issue can be done.
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Pain rating scale will be used continuously to
monitor reduction in pain level.
To check effectiveness of therapies and
medicines provided to the patient.
Evaluation:
Nursing care plan will be evaluated on the basis of various ways: after 6 hours of nursing
interventions, wound management, therapies pain level of patient should be reduced, stabled
vital signs of body relaxation should be observed. If pain level is 3 or less then three then patient
can be released with provided prescription.
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