University Healthcare Report: ISBAR Analysis of Patient Nasal Bleeding

This ISBAR report details the care of a patient, Mr. Y, admitted for nasal bleeding. The report, authored by a registered nurse, outlines the patient's situation, background, assessment, and recommendations. Mr. Y, diagnosed with juvenile nasopharyngeal angiofibroma, has been experiencing continuous nasal bleeding. The report covers the patient's history, including nasal obstruction and previous diagnoses. The assessment conducted at 1000HRS revealed that while the patient's heart rate and oxygen saturation were within normal limits, his respiratory rate was slightly elevated. The report recommends a nasal operation and a detailed care plan for post-surgery management, emphasizing the importance of monitoring vital signs and providing appropriate medications. The patient is also recommended to undergo speech review and a thickened diet to aid recovery. The report highlights the need for routine tracheostomy dressing and formulation of a post-surgery care plan.

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Name of the Student:
Name of the university:
Author note:

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Identification:
I am X, the appointed registered nurse who will take in-charge of evaluating the health
condition of the patient. I had to perform the clinical assessment to complete the handover for
the nurse who will review the patient in the second shift. The name of the patient is Mr Y,
who was admitted to the hospital for his nasal bleeding condition. The patient was initially
diagnosed with juvenile nasopharyngeal angiofibroma and was currently suffering from
continues nose bleeding from past 1 year. The data of birth of the patient was (), and was
currently XX years old.
Name of the Nurse-
Name of the patient-
Date of Birth (DOB)-
Situation:
The patient situation was deteriorating as the patient was suffering from continuous nasal
bleeding and required immediate patient-centred care to stop the bleeding. The patient
required medications and nasal packing for controlling his bleeding condition associated with
nasal obstructing operation. Once, the treatment is effective, the patient will be planned to get
discharged but has to take care of the health as the condition primarily arises due to nasal
tumor formation.
Background:
The patient was suffering from nasal obstruction from past six months and was also initially
diagnosed with Juvenile nasopharyngeal angiofibroma with intra cranial extension with
position tracheostomy. The patient exhibited inset in the insidious and was vegetarian by
choice. The patient was non-alcoholic and non-smoker and also used to sleep soundly. The

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bowel bladder habits are regular and exhibiting no negative symptoms. The patient only
exhibited the symptoms of nasal bleeding and was administrated with different medication
that would aim to improve the health condition of the patient. The patient is currently
presenting the issue of nasal bleeding and deteriorating health condition, hence, the patient
required an immediate surgical intervention as evaluated from the investigation findings.
Based on the treatment plan, it was suggested that the patient must approach for regular
dressing for his tracheostomy condition associated with deep breathing exercise.
Assessment:
The assessment was conducted for the patient at 1000HRS. Based on the physical
examination findings, it was seen that the heart rate of the patient was under control, the
oxygen saturation (spo2) rate of the patient was also under control and was absolutely
normal. The respiratory rate of the patient was little higher based on the standard value. The
patient was under rest and hence, the respiration rate in between the range of 12-25 breathes
per minute is considered abnormal and the patient had exhibited the RR rate of 24 breathes
per minute. Hence, the patient requires care regarding his respiration rate and other than the
vital sign assessment, the patient required a surgery in next three days to control the nasal
bleeding. The patient was not experiencing any severe pain condition and hence there was no
requirement of pain management. The vital sign assessment examination was required for the
before commencing the surgical process. The patient required a detailed care plan for
managing his nasal bleeding after surgery, which was due after three days. The patient
therefore required assistance regarding medications and the pre-operative procedure that is
very crucial for managing the condition of nasals bleeding before surgery.

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Recommendations:
The patient is recommended to undergo the nasal operation that will aim to relieve the
obstruction caused in his nasal by making a tracheostomy. The findings from the physical
emanation will be closely assessed and all the vital signs of the patient will be evaluated
before and after the surgery. The patient is also recommended to perform speech review that
will aim to initiate the trails of deflation of the cuff and is also suggested to undergo
thickened diet, which will improve his vital sign functioning and also help the patient to
recover from the health condition. The patient will be under observation after the surgery to
review the success of the intervention and if the patient is exhibiting any adverse health
outcome. The patient is recommended for routine tracheostomy dressing to avoid any
formation of puss or swelling. A care plan needs to be formulated stating the required
recommendation and medication requirement that the patient must follow to overcome from
the condition of bleeding post-surgery.