ISBAR Care Plan: Comprehensive Report on Thomas's Hip Fracture Care

This document presents an ISBAR (Introduction, Situation, Background, Assessment, Recommendation) care plan for a 77-year-old male patient named Thomas, who sustained a right traumatic hip fracture. The report outlines the patient's history, including pre-existing conditions and current health status. It includes the assessment of his central nervous system, cardiovascular system, neurovascular system, and other relevant systems. The document identifies the patient's problems, such as pain and concerns about his wife. The care plan details the planning phase, including expected outcomes and outcome criteria. Nursing interventions, such as providing commodes and administering medications, are also specified. The report emphasizes the importance of a healthy diet, mobility aids, and pain management. Evaluation and signature sections complete the care plan. The document is a valuable resource for healthcare students and professionals seeking to understand and implement ISBAR-based care planning for patients with hip fractures. This report is available on Desklib, a platform providing resources for students.

1 ISBAR Care Plan 2015
Identification
Please remember to use three identifiers to confirm correct patient:
ISBAR – Plan of Care
Patient name: Age / Date of Birth: Gender:
Thomas
77 Years
11/5/19xx
Male
Situation: Right traumatic hip fracture. It happens as
Thomas tripped over his dog at home and fell over.
Admission Diagnosis: Emergency surgery of hip
fracture
Background: It is stated that Thomas, 77 year old
male is a retired farmer and due to performing farming
activities he is absolutely fit and health. He is currently
living in Horizon. He has his loving wife Ivy and 3
children. He lives with his wife and 2 dogs, named
molly and Bess. It is stated that both Ivy and Thomas
are popular in their community as they have achieved a
lot in their lives. They also take active participation in
clubs and other community activities.
In addition, it is stated that at the age of 77. Thomas
still helps his son in farming process and it shows that
he is healthy and has capabilities of working in an
efficient manner. It is also stated that both Thomas and
Ivy become concerned about their health and take care
of each others. They have been aware and mindful of
the importance of their health and for this they also
make appointment to their GP or doctor in every 6
months.

2 ISBAR Care Plan 2015
History:
Some background details of Thomas medical condition
and history is being identified which include:
Immunization up to date.
Sporting and farming injuries like fracture in leg.
Used to smoke but has quite since 10 years
Nil known allergies
Nil regular medications
Feeling of stiffness in joints currently
Wound drained and Urinary catheter have been
removed.
Assessment:
CENTRAL NERVOUS SYSTEM: Alert and oriented
Cardiovascular system: Observation stable
Neurovascular system: Right foot.
GIT (gastrointestinal system): Ward diet
ADL’s (Activities of daily living): Minimum
assistance required. Hygiene and skin integrity assisted.
Ward diet as tolerable.
Skin integrity: hip wound
Objective Data Subjective Data
Wound on right hip Vital signs 4/24.
Neurovascular check 4/24
Dressing frequency 2/7 wound drain

Problems (actual or potential):
It is stated that Thomas feel over when he was playing and tripped over his dog at home Due to this, he felt a right traum
After that, he (Thomas) was placed by doctor in the CCU for 2 hours 7 days. Now because of this intervention and imm
Priority of problems:
One of the main needs is to make him feel comfortable and painless, fit as like he was before. After surgery, Thomas
Other main problem for which Thomas is concerned is Ivy, his wife. It is stated that his wife has become forgetful and be
3 ISBAR Care Plan 2015

4 ISBAR Care Plan 2015
Planning: Recommendations
Expected Outcome Outcome Criteria
Suggestions of living in rehab phase
Vital signs QID 4 times a day
Daily hip dressing To make independent
Encouraging a healthy diet including fluids. Timely recovery or curing hip fracture.
Following care plan and precaution prescribed
by the Doctor.
Nursing Interventions
Interventions Rational
e
Commode with seat raiser One of the main reasons of suggesting this is to help Thomas and the
patient in curing his hip injury. To make him feel relief in pain.
Mobility aids as directed by physio
Administration of oral medications Cure his hip injury in an efficient and timely manner.
Applying cool and warm compress
whenever required
Make him feel pain relief.

Evaluation:
5 ISBAR Care Plan 2015
Signature Date