NUR226: ISBAR Handover - Patient Assessment and Recommendations

This report presents an ISBAR (Identification, Situation, Background, Assessment, Recommendation) handover for a patient named Fred, who has a history of bowel cancer and is undergoing chemotherapy. The situation involves increased nausea and vomiting over the past three days, leading to decreased oral intake. Fred's background includes COPD, osteoarthritis, and type 1 diabetes. The assessment reveals a pulse rate of 96 bpm, low blood pressure, and oxygen saturation of 91% on 2L oxygen. He reports severe pain and has been vomiting. The GP observed 350ml of vomit with 30ml intake. Recommendations include hydration, IV medication administration, MRI, and antiemetic medication, alongside pain management and environmental considerations. The report emphasizes the importance of monitoring the patient's condition and taking necessary actions based on medical orders.

Running Head: Nursing
ISBAR Handover
Name of the Student
Name of the University
Authors Note

2ISBAR Handover
ISBAR Handover
Identification
Fred is a patient of bowel cancer and he has undergone form a bowel resection
surgery. He is receiving chemotherapy for last two weeks.
Situation
Fred went to local GP with increased nausea and vomiting. He has been suffering
these two symptoms for past three days. The person is experiencing nausea and vomiting
with decreasing oral intake. Fred is having nausea and is vomiting due to the chemo therapy
induced effects. The patient might show the hyperactive reaction or withdrawal sign for the
chemo therapy. The patient is needed to be stabilised.
Background
He has a history of COPD and Osteoarthritis. The patient has suffering from COPD
for 15 years. The Osteoarthritis is also present in his premedical history. As a result of
COPD, he uses salbutamol inhaler. However he smokes occasionally. He takes over-the -
counter (OTC) medication ibuprofen and paracetamol to reduce the pain by osteoarthritis. He
also has hyper glycaemia so he needs to take insulin after his meal. There is no mention about
the history related to allergy for the patient.
Assessment
His pulse rate is 96 bpm. He is having l0ow blood pressure with the readings of 110/60.
The respiratory rate is quite normal in him. Oxygen saturation rate is 91% on 2L of oxygen
with the help of nasal prong. He has severe pain with the reading 7/10 in pre analgesia dose.
The patient has been vomiting for three hours. According to the GP’ observation he has
vomited 350 mls with the intake of 30 mls. Hypoactive bowel sounds has been observed due
to abdominal assessment. Therefore his intestinal activity has been slowed down because of

3ISBAR Handover
cancer. No abnormality is present during respiratory assessment with normal lung sounds
and equal amount of air entry. His Blood glucose level is 5.3 mmol/L, which is normal. More
information and details
Recommendations
The person needs to be hydrated first and his vomiting must be stopped any way. As
the patient is unable to eat anything the medication must be administered to the body with the
help of IV cannulation . After that MRI should be suggested to observe the condition of
his body and especially any abnormalities in the brain . The patient Ondansetron or
Proclorperazine might be suggested as per patient’s condition. All the information regarding
the food intake such as the texture of the food, nature of the food, and timing of eating should
be noted. The patient or the family member or care giver must be asked whether any
medication like painkiller or antacids have been consumed by the patient or not. The patient
must be relaxed and calmed by distraction. The environment of ambulance should be
ventilated. Assessments of GP must be taken under consideration. The patient must be given
antiemetic as ordered. 5-HT3 receptor antagonist and dexamethasone might be given to the
patient as an emergency. If the patient is feeling extreme pain, he must be given analgesia.
Administration of drugs will be proceeded with the permission of respective doctor.