NUR226 Task 2: Nursing Handover Report: Patient Assessment and Plan

This report presents an ISBAR (Identification, Situation, Background, Assessment, Recommendation) handover, focusing on a patient named Florence/Fred Boyle with a complex medical history including COPD, osteoarthritis, and Type 1 diabetes. The report details the patient's admission observations, current symptoms (nausea, vomiting, pain), and relevant background information, including recent surgery and upcoming chemotherapy. The assessment covers vital signs, respiratory status, and blood glucose levels. The recommendations emphasize the importance of influenza vaccination, early disease management, medication adherence (insulin), and supportive therapies for osteoarthritis. The report aims to provide a clear and concise handover to facilitate safe and effective patient care, highlighting the need for ongoing monitoring, intervention, and communication among healthcare professionals.

Written Piece

TABLE OF CONTENTS
IDENTIFICATION..........................................................................................................................1
SITUATION....................................................................................................................................1
BACKGROUND.............................................................................................................................1
ASSESSMENT................................................................................................................................1
RECOMMENDATIONS.................................................................................................................1

IDENTIFICATION
The patient has been suffering from pain of 7/10 pre analgesia dose. There are hypoactive
bowel sounds. The patient has been vomiting for 350mls during the 4 hours at the time patient
has been at GP clinic. The BGL is 5.3mmol/L. The respiratory assessment has normal lung
sound and also equal set of air entry. At the time of the admission of the patient, it has been
observed that, Temperature is 36.7, Pulse rate was 90, Respiratory rate was 18, blood pressure
was 150/90 and the oxygen saturation was identified to be 97%.
SITUATION
Florence/fred boyle in turn has been admitted to surgical ward. He tends to have the history of
COPD for around 15 years. He also has Osteoarthritis and Type 1 diabetes. After surgery, the
patient was heading for blood transfusion because of anemia which eventually resulted in cardiac
arrest. This situation has been overcome by the patient because of great medical team support.
The nurses within the care home tends to provide wound care for the bowel cancer.
BACKGROUND
The patient has been transported to the hospital for the monitoring and hydration purpose. This
study will focus on determining the safe and evidence-based assessment, planning, interventions
and evaluation specific to the nursing practice.
ASSESSMENT
Florence has been taking salbutamol inhaler for the COPD. For the Osteoarthritis the patient has
been taking over the counter medication paracetamol PRN and ibuprofen. For the Type 1
diabetes he needs to take insulin with the meal. The observations of the patient are Temp 374,
pulse 96, bpm BP11060, RR26, Sats 91 on 2L 02 via NPs. There seems to be increased level of
vomiting and nausea and pain in the leg and back of the Florence.
RECOMMENDATIONS
The patient is about to start the Chemotherapy and the patient has been recommended to take
influenza vaccine prior the commencement of the treatment. Early based disease management
plan and education to the nurses in turn are considered to be one of the effective evidence based
practice and intervention to treat COPD. The nurses tends to focus on giving prescribed set of
insulin and eat healthy balanced diet helps in improving Type 1 diabetes. The nurses tends to
focus on maintaining the healthy weight of the patient by eating healthy and exercising regularly.
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The nurses keep the count of protein, fat and carbohydrate in order to improve Type 1 diabetes.
The nurses also focuses on providing occupational and physical therapy for the improvement in
the results of osteoarthritis. The nursing intervention for the osteoarthritis tends to focus on
reducing the pain of the patient and also leads to optimal functional ability. The nurses uses
assistive devices and also tends to focus on weight loss which leads to better care results and
outcomes of the patients. The nurses will also focus on time to time evaluating the health
outcomes of the patient and trained nurses will carry out Chemotherapy for bowel cancer.
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