You should aim to answer these questions as part of your ISBAR handover:
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Get Help Now!1. What is the pathophysiology of the client’s current condition(s)? What is your assessment of the client’s current medication including pharmacology and pharmacokinetics?
2. Consider the patient/collect cues- what information do you have?
3. Assessments required- What further information do you need or would like prior to your visit?
4. Identify problem/Issue- why are you visiting them? What will you do once there?
5. Establish Goal- What is it that you aim to achieve through your care and how will you undertake the care required?
6. Evaluation- what strategies will you use to evaluate the outcomes?
case study:
Patient 4: Estimated consult time 2-3hrs
Mrs. Rebecca Smyth
Street address: 118 The Boulevarde, Lewisham. NSW
Age 44
Medical History: Relapsing – Remitting Multiple Sclerosis (RRMS) diagnosed three years ago.
Current medical history: Symptoms of spinal syndrome characterised by paraesthesia, pain, muscle spasms and spasticity. Muscle weakness and stiffness in her limbs Increasingly experiencing pain and fatigue Sense of hopelessness. Impaired vision which makes reading more difficult Diplopia which affects her balance. Slurred speech
Social History: Rebecca lives with her husband Jim in a ground floor apartment. They have one daughter, Tiffany, 8 years old. Jim runs the family plumbing business from home but is often out on the road. Rebecca left her position as a customer relations officer with Westpac and is trying to maintain the books for Jim’s business. House has overgrown front yard and 3 broken steps to the front door.
Current medication: Baclofen 5 mg TDS Diazepam 5 mg nocte Trial of Gabapentin 300 mg mane
Current issue being managed: Pain management and increase in symptomology
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