ISBAR Case

Jimmy Bell, DOB 02/02/85, a male was brought into the Emergency Department after sustaining
gun-shot wounds to the left chest/abdomen. After a quick assessment and stabilization, Nurse
Rowan took the patient to the operating room, where the surgeons performed an exploratory
laparotomy to determine the extent of the wounds. His diagnosis, post-surgery, is status post
exploratory lap, splenectomy, left thoracotomy, and placement of a left chest tube. Mr. Bell is
extubated and taken to the post anesthesia care unit (PACU). During the first half-hour there is a
decrease in left breath sounds and an increase (450 ml) in sanguineous fluid in his chest tube
evacuation device, and Mr. Bell awakens to name, but drifts off easily. His blood pressure is
90/60, hear rate 110, and respirations 28.
Assignment: You are the nurse and need to inform the acute care nurse practitioner in the PACU
about Mr. Bell’s rapid change in assessment. You thing that the patient is in need of immediate
attention from either the nurse practitioner or his physician. Use ISABAR to convey this
information to the acute care nurse practitioner.
Submission Instructions: Attach this page to the front of your assignment (5 points if
missing)
Documentation and Communication paper
Professional communication and Case Study analysis using ISBAR. Things to address in this
two-page paper:
 Introductory overview of effective communication techniques. Include thoughts on how
pertinent this is to the nursing profession as it relates to leadership and management.
 Identify the pertinent information from the case study and place it in an ISBAR template.
Bullet point format is acceptable.
 ISBAR summary narrative as it relates to the case study (the written conversation you
would have).

Content Points Comments

Possible
Overview of effective professional 25
communication.
Addresses each ISBAR element. 50
(Bullet form)
Narrative summary statement.
Demonstrate clear thought
processes as it applies to ISBAR 25
and the Case Study.
Total Points 100
Ashley King
ISBAR
3/7/19

Communication is one of the most important elements of patient safety in the nursing

profession. ISBAR is a general framework for health care teams to communicate effectively.

Everyone on the health care team is accustomed to this framework and that’s what makes ISBAR

so effective. Understanding the elements of ISBAR and what information is valid is very

important. This framework if communicated effectively minimized communication gaps and

catches physicians attention. Every element of ISBAR is important and relevant. Introduction;

this is the time to introduce yourself, your role, your patient, and the unit you are calling from.

This is also the time to make sure you have the right person on the other end of the line.

Situation; this is the time to state what has happened so you can catch that physician’s attention.

State your problem, the current condition and concerns. Background; now this is the time to

give that brief synopsis of your patient. For example, their diagnosis, history, abnormal labs,

allergies, medications so the physician can use this information to hopefully understand why the

situation is happening. Assessment; this is when the big part of the nursing role comes in. This is

the time to make sure you have assessed your patient before you call the physician. You need an

updated assessment, set of vitals, summary of patient’s condition, stating the problem you have

observed, and giving specific signs and symptoms that have changed from the patient’s baseline.

Recommendation; this is when the provider is going to make suggestions for the patient’s care

plan moving forward and also the time for the nurse to state what they would like to see done.

This is the time to ask to see the physician if you feel that is necessary. Ask the provider when

they would like to be re-notified of the patient’s condition after the new care plan is put in place.
Introduction
 Ashley from PACU
 Mr. Bell’s nurse
 Is this the NP on the PACU floor?
Situation
 In the first half-hour in the PACU he has had a diminish in left breath sounds and 450ml
in sanguineous fluid from his chest tube
Background
 Mr. Bell was brought to the ED after sustaining gun-shots to the left chest and abdomen
 Mr. Bell is post-surgery from an exploratory lap, splenectomy, left thoracotomy, and
placement of left chest tube
 He has been extubated
Assessment
 Mr. Bell awakens to name but drifts off easily
 BP 90/60, HR 110, RR 28
 Decreased left breath sounds and increase in of 450ml of sanguineous fluid from chest
tube
Recommendation
 Come see patient
 Change in care plan while waiting?

Narrative: Hello this is Ashley from the PACU. I am Jimmy Bell’s nurse, is this the NP in the
PACU I’m speaking to? In Mr. Bell’s first half hour in the PACU he has had a diminish in left
breath sounds and an increase of 450mL in sanguineous fluid from his chest tube. Mr. Bell was
brought to the ED after sustaining gun-shot wounds to the left chest and abdomen. After being
stabilized in the ED he was taken to surgery for an exploratory lap. Mr. Bell is now post-surgery
from an exploratory lap, splenectomy, left thoracotomy, and placement of a left chest tube. He
has been extubated and brought to PACU. Mr. Bell’s VS are BP 90/60, HR 110, RR 28. He
awakens to his name but drifts off easily. As stated before he has a decrease in left breath sounds
and an increase of 450mL in sanguineous fluid from his chest tube. I would like for you to come
see Mr. Bell as soon as possible due to his rapid change in assessment. Is there anything you
would like me to change in the plan of care as of right now? When will you be by to see Mr.
Bell?