HACN I Fundamentals of Care Plan & ISBAR Handover

HACN I Fundamentals of Care Plan & ISBAR Handover

Case 1

Joyce Coombe is a 65-Year-old lady who presented to the Emergency dept. last night.

Joyce has been suffering with what feels like flu symptoms for the past week. She has an irritating productive cough and her sputum is green. Joyce has a history of asthma and the flu has exacerbated her symptoms. She presented with shortness of breath, wheezing on inspiration, she is flushed and sweaty (diaphoretic) and has a temperature of 38.8deg. She is complaining of sore chest muscles from coughing, she has a headache and achy joints. She appears and feels exhausted.

Joyce has a history of Type II Diabetes, Asthma for 20 years and Osteoarthritis. Joyce is a smoker and smokes 10 per day. She has been trying to reduce this with not much success.

Surgical history includes a Cholecystectomy 25 years ago.

She suffers with depression and is currently not on any medication for this.

After some initial tests were performed Joyce is diagnosed with Infective Bronchitis and she is admitted to your respiratory ward for rest and treatment.

Joyces husband accompanied her to the ward and made sure she was settled in before going home. He will visit daily but is not a well man and he has to catch the bus. He will call if he can-not visit. You have collected his details and written this in Joyces progress notes.

Tests performed in the emergency dept.

Chest Xray

FBE (full blood examination)

HB (Haemoglobin)

Sputum specimen

Urine specimen

Treatment orders for ward management.

The medical orders are for Oxygen via nasal cannula @ 2L/min to maintain oxygen saturations 90-95%

Spirometry readings to be done before and after bronchodilators

A high protein, diabetic diet has been ordered

Joyce is to be encouraged to increase her intake of oral fluids.

Twice daily blood glucose readings (BD)

She is to be commenced on a fluid balance chart (FBC) and diabetic food chart and is to have second daily weighs.

Access the RDR chart, FBC chart and medication chart and consider the data provided.

Question 1:

Focusing just on two (2) of the Physical Fundamentals of Care you are to develop a plan of care identifying the nursing interventions you will provide to meet Joyces care needs in relation to her current problems and your chosen physical fundamental of care.

Fundamental of care

Firstly you will state the fundamental of care you will provide and why this is necessary for this patient in relation to her current diagnosis. (Example: Increase her fluid intake to improve her hydration status and kidney function). References required

Goal of care

State your goal of care (What are you hoping to achieve, what improvements you will see and measure?)

Nursing interventions

Outline the specific bedside nursing interventions you will perform to achieve your goal, giving a rationale for each. References required

Clinical outcomes

Lastly state the indicators that your plan is working (What improvements can you see or measure in the patient because of the interventions?) References required.

Please use headings for each new section

Word count 750 1000 for each care plan

Question 2:

It is now the end of your early shift, you are to write a handover that you will read to the late staff using the ISBAR format. Only include the important information that the nurse on the next shift will need to care for Joyce on the following shift.

You are to include her medications and state why these have been ordered for Joyce (See the medication chart)

You are to state her most recent vital signs and state if they are within normal ranges.

You are to include the information on the treatment order.

The PPT presentation is available and has a more detailed description of what is required in each domain.

Please use headings for each domain.

Word counts approx. 750 - 1000 words

Please reference any material where you need to clarify a diagnosis, state normal ranges for vital signs or rationale for medication.

Please include a reference list at the end of your paper. All material that you have researched must be referenced as this demonstrates your learning and your ability to access evidenced based research.