ISBAR (Identify, Situation, Background, Assessment, Recommendation) is a tool used to communicate clearly and effectively with colleagues in healthcare settings. It is a structured way of presenting information about a patient's situation, history, and current status, as well as any recommendations or actions that need to be taken.

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BRANDON SHARP Spinal Cord Injury

ISBAR:

• Situation: Subacute rehabilitation unit

• Background: Mr. Sharp was involved in a car accident and sustained a spinal cord injury. He is currently in the subacute rehabilitation unit and is receiving physical therapy and occupational therapy.

Nursing care plan:

• • Risk for skin breakdown related to limited mobility and immobility

• Expected outcomes:
• • Monitor Mr. Sharp's skin regularly and assist with skin care as needed

  • Educate Mr. Sharp on the importance of skin care and prevention of skin breakdown

WILLIAM EDWARDS Acute Ischemic Stroke

ISBAR:

• Recommendation: It is recommended that Mr. Edwards receive urgent treatment for his stroke, including intravenous tPA (tissue plasminogen activator) if appropriate. The nursing team should closely monitor Mr. Edwards for any changes in his condition and coordinate with the medical team to ensure timely and appropriate care.

Nursing care plan:

• Nursing diagnoses:
• • Mr. Edwards will be free from injury

• Interventions:

LILING ZHAO Implantable Cardioverter Defibrillator

ISBAR:

• Situation: Emergency department

• Background: Ms. Zhao has an implantable cardioverter defibrillator (ICD) for management of her arrhythmias. She has arrived at the emergency department with chest pain and shortness of breath.

Nursing care plan:

• • Ineffective coping related to fear of ICD shocks

• Expected outcomes:
• • Encourage and assist Ms. Zhao with relaxation techniques or other coping strategies to manage her anxiety

  • Coordinate with the medical team to address any concerns or questions Ms. Zhao may have about her ICD

CHARLES JONES Acute Decompensated Heart Failure

ISBAR:

• Recommendation: It is recommended that Mr. Jones continue with his current treatment and that the nursing team assess his adherence to his medications and lifestyle modifications. The nursing team should also provide

Nursing care plan:

Nursing diagnoses:

Expected outcomes:

• Mr. Jones will demonstrate improved respiratory status with normal breath sounds and oxygen saturation

• Assess Mr. Jones's respiratory status and oxygen saturation regularly

• Administer oxygen as prescribed

• Provide information about the importance of adherence to medications and lifestyle modifications, such as taking medications as prescribed and following a low-salt diet

• Coordinate with the medical team to address any concerns or questions Mr. Jones may have about his condition and treatment.

TONY WALLACE Sickle Cell Crisis

ISBAR:

• Recommendation: It is recommended that Mr. Wallace continue with his current treatment and that the nursing team closely monitor his pain management and hydration status. The nursing team should also provide education to Mr. Wallace about sickle cell disease and strategies to prevent future crises.

Nursing care plan:

Nursing diagnoses:

• Mr. Wallace will be free from infection

Interventions:

RAMESH PAHEL Kidney Stones

ISBAR:

• Identify: Ramesh Pahel, kidney stones

• Situation: Emergency department

Nursing care plan:

• • Acute pain related to kidney stones

  • Limited knowledge about kidney stones and their management

• • Administer pain medication as prescribed

  • Educate Mr. Pahel about kidney stones, including their causes, symptoms, and management

VALERIE CUCINA Gastrointestinal Bleeding

ISBAR:

• Assessment: Ms. Cucina's vital signs are stable, but she is experiencing abdominal pain and has limited oral intake. She reports a history of acid reflux and nonadherence with her medications.

• Recommendation: It is recommended that Ms. Cucina continue with her current treatment and that the nursing team assess her adherence to her medications and lifestyle modifications. The nursing team should also provide education to Ms. Cucina about peptic ulcers and strategies to prevent future episodes of gastrointestinal bleeding.

Nursing care plan:

• Expected outcomes:

  • Ms. Cucina will report pain control with medication
• • Encourage and assist Ms. Cucina with oral intake as tolerated

  • Educate Ms. Cucina about peptic ulcers, including their causes, symptoms, and management

MARIA GONZALES Gallstone Pancreatitis

ISBAR:

• Situation: Intermediate care unit

• Background: Ms. Gonzales has been admitted to the intermediate care unit with acute pancreatitis secondary to gallstones. She is receiving pain medication, intravenous fluids, and antibiotics.

Nursing care plan:

• • Risk for malnutrition related to limited oral intake

• Expected outcomes:
• • Encourage and assist Ms. Gonzales with oral intake as tolerated

  • Educate Ms. Gonzales about gallstones, including their causes, symptoms, and management

RUTH LIVINGSTON Hip Fracture

ISBAR:

• Assessment: Ms. Livingston's vital signs are stable, but she is experiencing pain and discomfort. She reports limited mobility and difficulty with self-care activities due to her injury.

• Recommendation: It is recommended that Ms. Livingston continue with her current treatment and that the nursing team assess her pain management and mobility needs. The nursing team should also provide education to Ms. Livingston about her injury and post-surgical care.

Nursing care plan:

• Expected outcomes:

  • Ms. Livingston will report pain control with medication
• • Encourage and assist Ms. Livingston with mobility and self-care activities as tolerated

  • Educate Ms. Livingston about her injury, including the type of surgery she will undergo and the expected recovery process

DALE MAY Hepatic Cirrhosis

ISBAR:

• Situation: Oncology unit

• Background: Mr. May has hepatic cirrhosis and has been admitted to the oncology unit with worsening fatigue, jaundice, and abdominal pain. He is receiving intravenous fluids and medications to manage his symptoms.

Nursing care plan:

• • Risk for impaired liver function related to nonadherence with medications and lifestyle modifications

• Expected outcomes:
• • Educate Mr. May about hepatic cirrhosis, including its causes, symptoms, and management

  • Provide information about strategies to prevent further deterioration of liver function, such as taking medications as prescribed and avoiding alcohol

JARED GRIFFIN Asepsis and Infection Control

ISBAR:

• Situation: Medical-surgical unit

• Background: Mr. Griffin has been admitted to the medical-surgical unit with pneumonia and is receiving intravenous antibiotics. He is at high risk for infection due to his compromised immune system and is being isolated in a private room.

Nursing care plan:

• • Risk for malnutrition related to limited oral intake

  • Risk for infection related to compromised immune system and COPD

• Interventions:

  • Assess Mr. Griffin's respiratory status and oxygen saturation regularly

  • Implement infection prevention measures such as hand hygiene, respiratory etiquette, and isolation precautions as needed

  • Coordinate with the medical team to address any concerns or questions Mr. Griffin may have about his condition and treatment.

JOSEPHINE MORROW Skin Integrity and Infection Control

ISBAR:

• Recommendation: It is recommended that Ms. Morrow continue with her current treatment and that the nursing team assess her pain management and skin care needs. The nursing team should also provide education to Ms. Morrow about skin integrity and strategies to prevent future skin breakdown.

Nursing care plan:

• Nursing diagnoses:

• • Ms. Morrow will report pain control with medication

  • Ms. Morrow will demonstrate improved mobility with assistance as needed
• • Educate Ms. Morrow about skin integrity and strategies to prevent skin breakdown, such as reposition

KIM JOHNSON Urinary Elimination: Intermittent Catheterization

ISBAR:

• Identify: Kim Johnson, urinary elimination: intermittent catheterization

Nursing care plan:

• Nursing diagnoses:

  • Acute pain related to intermittent catheterization
• • Ms. Johnson will demonstrate improved mobility with assistance as needed

  • Ms. Johnson will be free from urinary tract infection

• • Provide information about strategies to prevent urinary tract infections, such as proper hand hygiene, catheter care, and voiding as prescribed

  • Implement infection prevention measures such as hand hygiene and catheter care as needed

MARVIN HAYES Bowel Elimination Colostomy Care

ISBAR:

• Assessment: Mr. Hayes's vital signs are stable, but he is experiencing discomfort and has limited mobility due to his surgery. He reports limited understanding of his condition and is concerned about the appearance and function of his colostomy.

• Recommendation: It is recommended that Mr. Hayes continue with his current treatment and that the nursing team assess his understanding and comfort with his condition. The nursing team should also provide education to Mr. Hayes about colostomy care and strategies to manage his bowel function.

Nursing care plan:

• Ineffective coping related to limited understanding of colostomy care

• Deficient knowledge related to colostomy care

• Mr. Hayes will express understanding of and coping with his colostomy

• Mr. Hayes will demonstrate proper colostomy care techniques

• Provide emotional support and encouragement to Mr. Hayes as he adjusts to living with a colostomy

• Implement infection prevention measures such as hand hygiene and colostomy care as needed

HENRY WILLIAMS COPD Exacerbation

ISBAR:

• Assessment: Mr. Williams' vital signs are stable, but he is experiencing difficulty breathing and has limited oral intake. He reports a history of poor adherence with his medications.

• Recommendation: It is recommended that Mr. Williams continue with his current treatment and that the nursing team assess his adherence to his medications and oxygen therapy. The nursing team should also provide education to Mr. Williams about COPD and strategies to prevent future exacerbations.

Nursing care plan:

• • Ineffective health maintenance related to poor adherence with medications

• Expected outcomes:

• Interventions:

  • Assess Mr. Williams' respiratory status and oxygen saturation regularly

  • Implement infection prevention measures such as hand hygiene, respiratory etiquette, and oxygen therapy as needed

  • Coordinate with the medical team to address any concerns or questions Mr. Williams may have about his condition and treatment.

JULIA MORALES and LUCY GREY Coping After the Loss of Partner

ISBAR:

MILLIE LARSEN Fall Risk and Functional Assessment

ISBAR:

• Identify: Millie Larsen, fall risk and functional assessment

• Situation: Rehabilitation center

Nursing care plan:

• • Acute pain related to fall

  • Impaired physical mobility related to fall
• • Ms. Larsen will demonstrate improved mobility with assistance as needed

  • Ms. Larsen will be free from falls
• • Educate Ms. Larsen about fall prevention, including strategies such as using assistive devices, maintaining a safe environment, and managing medications

SHERMAN "RED" YODER Possible Sepsis

ISBAR:

• Identify: Sherman "Red" Yoder, possible sepsis

Nursing care plan:

• Nursing diagnoses:

  • Fever related to sepsis

• • Mr. Yoder will have normalized temperature

  • Mr. Yoder will have stable vital signs
• • Administer antibiotics and fluids as prescribed

  • Encourage and assist Mr. Yoder with oral intake as tolerated

VERNON RUSSELL Muscoloskeletal System Assessment

ISBAR:

• Identify: Vernon Russell, musculoskeletal system assessment

• Situation: Outpatient clinic

Nursing care plan:

• • Chronic pain related to musculoskeletal condition

  • Impaired physical mobility related to chronic pain
• • Mr. Russell will demonstrate improved mobility with assistance as needed

  • Mr. Russell will be free from falls

CARL SHAPIRO Acute Myocardial Infarction: Ventricular Fibrillation

ISBAR:

• Identify: Carl Shapiro, acute myocardial infarction: ventricular fibrillation

• Situation: Cardiac catheterization laboratory

Nursing care plan:

• • Acute pain related to myocardial infarction

  • Decreased cardiac output related to ventricular fibrillation
• • Mr. Shapiro will have stable vital signs

  • Mr. Shapiro will be free from infection
• • Encourage and assist Mr. Shapiro with oral intake as tolerated

  • Educate Mr. Shapiro about acute myocardial infarction, including its causes, symptoms, and management

Here are the ISBAR and nursing care plans for some of the fundamental patient scenarios for nursing students:

Christopher Parrish – Nutrition:

ISBAR:

• Introduction: Hello, my name is [Name] and I am the nurse caring for Christopher Parrish.

Nursing Care Plan:

• Goal: Christopher will maintain his current weight or achieve weight gain, as appropriate, and meet his nutritional needs.

• Interventions:

  • Educate Christopher and his family about the importance of meeting nutritional needs and ways to manage symptoms of Crohn's disease.

Edith Jacobson – Activity:

ISBAR:

• Introduction: Hello, my name is [Name] and I am the nurse caring for Edith Jacobson.

Nursing Care Plan:

• Goal: Edith will improve her strength, mobility, and activity level.

• Interventions:

  • Educate Edith and her family about the importance of maintaining strength and mobility, and ways to safely participate in activities.

Mona Hernandez – Oxygenation:

ISBAR:

• Introduction: Hello, my name is [Name] and I am the nurse caring for Mona Hernandez.

Nursing Care Plan:

• Goal: Mona will improve her oxygenation status and reduce her shortness of breath.

• Interventions:

  • Monitor Mona's oxygen saturation and shortness of breath.

  • Educate Mona and her family about the importance of managing COPD and the benefits of quitting smoking.

Rashid Ahmed – Fluids, Electrolytes, and Acid-Base Balance:

ISBAR:

• Recommendation: I recommend that Rashid be referred to a dietitian to assess his fluid and electrolyte needs and develop a plan to help him manage his imbalances. In the meantime, I will administer prescribed IV fluids and electrolytes, and encourage Rashid to drink fluids and eat foods that are high in electrolytes.

Nursing Care Plan:

• Goal: Rashid will maintain a balanced fluid and electrolyte status and improve his hydration.

• • Administer prescribed medications to manage diabetes and diarrhea.

  • Monitor Rashid's hydration status and electrolyte levels.

Sara Lin – Pain Management:

ISBAR:

• Assessment: Sara's pain is likely due to her surgery and endometriosis.

• Recommendation: I recommend that Sara be prescribed appropriate pain management medication and that we implement non-pharmacologic pain management techniques, such as heat therapy and relaxation techniques.

Nursing Care Plan:

• • Encourage Sara to communicate her pain level and discomfort using a pain scale.

  • Monitor Sara's pain level and response to pain management interventions.

Vernon Russell – Safety:

ISBAR:

• Assessment: Vernon's risk for falls is likely due to his stroke, weakness, and medications.

• Recommendation: I recommend that Vernon be referred to a physical therapist to assess his balance and coordination, and develop a plan to help him improve his safety. In the meantime, I will implement fall prevention measures, such as installing grab bars and providing a bed alarm.

Nursing Care Plan:

• • Encourage Vernon to use assistive devices, such as a cane or walker, as needed.

  • Administer prescribed medications as directed.