Scribd
Upload
6K views3 pages

ISBAR Progress Notes

Mr. Justin Breather, a 55-year-old male from Camperdown, Sydney, was brought to the hospital by ambulance in the early morning due to chest pain and difficulty breathing while sleeping. He has a history of smoking for 15 years, coronary bypass surgery in 2009, asthma, hypertension, and insulin-dependent diabetes. His vital signs upon admission showed an elevated heart rate and blood pressure, rapid breathing, and signs of ischemia on his ECG. The nursing plan is to give medications for chest pain and hypertension as ordered, continue cardiac monitoring, reassess his ECG, and schedule him for an echocardiogram.

Uploaded by

Francoruss
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
6K views3 pages

ISBAR Progress Notes

Mr. Justin Breather, a 55-year-old male from Camperdown, Sydney, was brought to the hospital by ambulance in the early morning due to chest pain and difficulty breathing while sleeping. He has a history of smoking for 15 years, coronary bypass surgery in 2009, asthma, hypertension, and insulin-dependent diabetes. His vital signs upon admission showed an elevated heart rate and blood pressure, rapid breathing, and signs of ischemia on his ECG. The nursing plan is to give medications for chest pain and hypertension as ordered, continue cardiac monitoring, reassess his ECG, and schedule him for an echocardiogram.

Uploaded by

Francoruss
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

UNIVERSITY HOSPITAL

Title
Family Name
Mr. BREATHER
Given Names
JUSTIN
Address
Street
18 MARSDEN STREET
Suburb
Postcode
CAMPERDOWN
2050

M.R.N.

123456

Age
Sex
55
M
Adm. date
15/08/2015

15/08/15

NURSING- Mr. Breather, a 55 y/o patient from Camperdown,

09:20

Sydney was brought in by ambulance due to chest pain and difficulty of


breathing early morning while sleeping. Wife called the

DOB
18/12/1960

triple zero for help. The patient has a history of smoking for
15 years, a coronary bypass surgery in 2009, asthma, hypertenSion , and insulin dependent diabetes mellitus. Medication
History includes Amlodipine as maintenance drug for HTN.
Vital signs are as follows: HR=100, BP= 180/110, RR=24, O2=
95% on 4LPM nasal prongs, T=37.0, BSL=10.2. ECG shows signs
Of ischemia with T-wave inversion on the reading. Plan includes
Administration of medications for chest pain and HTN as
Ordered by the doctor. Continue cardiac monitoring and do
ECG reassessment. Schedule the patient for 2D echo.
([Link], RN)

Title Family Name Mr. BREATHER M.R.N. 123456 Given Names JUSTIN Address Street 18 MARS

You might also like