Participation Requirement: You are required to post a minimum of three (3) times in each discussion. These three (3) posts must be on a minimum of two (2) separate days.

Part 1

Scenario: Mr. Smith, a 65 year-old man, has a history of COPD and hypertension. He also has type 2 diabetes. Due to COPD exacerbations, he has been hospitalized several times over the last year. The care plan was developed by an inter-disciplinary team and included continuity of care, from admission through successful discharge. There were follow up visits and monitoring.

Upon admission, the nurse assessed Mr. Smith’s respiratory status and initiated appropriate interventions such as oxygen therapy and nebulizer treatments. The nurse provided instruction about proper breathing techniques and inhaler technique. He adjusted the doctor’s medications to lower inflammation and started a steroid program. The care team collaborated to develop a comprehensive plan of care that included ongoing assessment of Mr. Smith’s respiratory status, medication management, and patient education on self-management strategies.

During his hospitalization, the case manager initiated discharge planning and arranged for follow-up appointments with Mr. Smith’s primary care provider, pulmonologist, and home health agency. Home health nurses visited Mr. Smith to provide additional education about self-management and how to manage medication. He was able to keep his medications on track and the case manager scheduled his appointments with his healthcare providers.

Biswas and co-authors (2018) found evidence to support this strategy. They studied the effects of a comprehensive discharge plan that included follow-up care for patients suffering from COPD.

Part 2

ISBAR report

Introduction: “Hello, this is [Nurse’s name] To call, dial from [facility name]. I am calling about Mr. Smith, a 65-year-old male with a history of COPD who was recently discharged home after a hospitalization for exacerbation of his symptoms.”

Situation: “I am calling because Mr. Smith is having a mild exacerbation of his COPD. He is experiencing increased shortness of breath and difficulty with activities of daily living.”

Background: “Mr. Smith suffers from COPD, hypertension, type 2 diabetes, and has had previous medical issues. Following an acute flare-up of his symptoms, Smith was released from the hospital and allowed to return home. He was prescribed a steroid regimen and oxygen therapy, and he has been following up with his primary care provider and pulmonologist as scheduled.”

Assessment: “Upon assessment, Mr. Smith’s respiratory rate is 28 breaths per minute, his oxygen saturation is 90% on room air, and he is experiencing increased shortness of breath with minimal activity.”

Recommendation: “I recommend that Mr. Smith be evaluated for possible admission for further management of his symptoms. Would you like me to contact the hospitalist to arrange for admission?”

Overall, the ISBAR report provides a structured approach to communication that promotes continuity of care and ensures that the physician is fully informed of the patient’s situation and needs.

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