ISBAR clinical handover framework Nursing Case Study Report

The case report must include the following:

Introduction – 200 words

Using the ISBAR clinical handover framework, introduce the person and provide a brief overview of their case. Provide an outline of the purpose and structure of the report.

Primary admission – 300 words

In this section provide a summary of the reasons why the person was admitted to hospital. For this, include a brief description of the pathophysiology of the person’s sustained injuries and their clinical manifestations. Support this discussion with contemporary, evidence-based literature.

Identify two (2) nursing problems (300 words)

Using the previous description of the pathophysiology and observed clinical manifestations, identify two (2) nursing problems that are to be prioritised for the person. Justify your selection and briefly describe why each is important in the person’s management. Support your discussion by utilising contemporary, evidence-based literature.

Tip: Importantly in this section, you should prioritise the care that is required by the person. Consider what is the most pressing concern for the person at this stage.

Nursing management (1000 words – 500 words per problem)

In this section, you will focus on the implementation of the nursing process to each of the identified problems from the section above. That is, for each identified problem you will need to include a discussion of;

· One (1) appropriate nursing assessment and its rationale,

· One (1) appropriate nursing intervention related to your assessment. Provide a rationale for each intervention,

· Nursing implications related to the medication management of the ongoing management of each problem.

Support your discussion by utilising contemporary, evidence-based literature.

Tip: This section of the report focuses on assessments and interventions that the Registered nurse (RN) conducts. Remember to discuss what the RN physically does to provide optimal person-centered care as part of the nursing management plan.

Discharge planning (500 words)

The discharge plan must focus on the interdisciplinary management for this person and should refer to the nursing problems addressed throughout the report.

In this section, discuss the aim of discharge planning and the importance of using an interdisciplinary approach. Also, discuss the role of the RN in facilitating a multidisciplinary discharge plan for this person. Identify and justify the members of the multidisciplinary health care team and the role that they would play. For this, you should refer back to the identified nursing problems discussed in the report.

Tip: Avoid reverting to simple referrals to other members of the health team.

Conclusion (200 words)

Summarise the major findings of this case report. The conclusion should not introduce new material that has not been previously addressed within the report.

Referencing

The content of the case report must be supported through referencing of current evidence-based literature and must include a reference list and intext citations. Students will be assessed on referencing and academic writing.

Clinical Scenario

​Identify

Patient Name
Mr Brian May,

Age/Date of Birth
62 years, 10/Nov/1960

Sex
Male

Situation

Mr May was admitted to the emergency department earlier today following a motor vehicle accident car versus tree on Old Stump Road, Wudinna that occurred at 5.30am. It is suspected that Mr May experienced a medical event that caused him to lose control of his car. At the time witnesses suggest the car was travelling at 50 km.hr-1.

BackgroundMr May is recently widowed after his wife died of pancreatic cancer 6 months previously. He now lives alone in the rural town of Wudinna. He reported to the ambulance personnel and staff at the hospital that he is non-compliant with his medication leading to unstable status of his diagnosed type 2 diabetes mellitus.
Mr May’s past medical history includes:

Type 2 diabetes mellitus.
Hypercholesterolaemia.
Depression.
Hypertension.
Current smoker 25 cigarettes a day.
Recent weight gain of 15 kg in the last 3 months. BMI now 30.
ETOH 50 g daily.
His currently prescribed medications include:

Atenolol (100mg bd)
Atorvastatin (80mg daily)
Metformin (500 mg bd)

Assessment

​
In the accident, Mr May sustained the following injuries:
Left pneumothorax and blunt chest injuries.
Fracture left fibula.

Left sided laceration of his forehead.

Recommendations

Thus, it was recommended that.

Plaster cast be applied to fractured left fibula – The orthopaedic registrar applied the plaster of Paris cast in the ED.
Patient controlled analgesia commenced for pain relief. Fentanyl 500 microg in 50 mL of Normal Saline at 2 mL per bolus dose.
Oxygen therapy at 2 L.min-1 administered via nasal specs.
Under water seal drain (UWSD) inserted in the Emergency Department by the trauma registrar.
Dressing to his head laceration.
Admission to the High Dependency Unit (HDU).
PCR testing for COVID-19.

Nursing Handover
​
It is 24 hours post admission, you are about to start your early shift in the High Dependency Unit and Mr May is your allocated patient.
During the morning bedside handover, the night duty Registered nurse (RN) reports Mr May had a restless night, slept for short periods only and at times was disorientated.
Tested positive for COVID 19 – enhanced respiratory precautions.

Vital signs (last measured at 0600):

Temperature: 37.6oC.
Heart rate: 100 beats per minute and regular.
Respiratory rate: 24 breaths per minute. Mr May complains of pain on inspiration and his breathing continues to be laboured.
It is noted that he is pale and diaphoretic.
Blood Pressure 170/90 mmHg.
UWSD observations; no swinging, bubbling or drainage.
Oxygen therapy continues as ordered.
During the nightshift, a total of 240 microg of Fentanyl IV was administered via the PCA.

An arterial blood gas (ABG) was ordered and taken at 0600 also. The following results were obtained:

pH = 7.30
PaO2= 68 mmHg
PaCO2 = 59 mmHg
Hb SaO2 = 92%
HCO3-1 = 26 mEq.L-1

Mr May continues to be restless and is now complaining of chest tightness when he breaths.

Also- I live in Australia.
Can references also please not be older then 6 years old and also be from legitimate scientific proper sites. if that makes sense

Thank you so much!!