This assessment supports you to achieve the following
Classify nursing care needs of patients using nursing diagnosis terminology
Construct nursing care plans for patients with medical care needs utilising nursing diagnosis and nursing interventions
Aim of Assignment
The aim of this assignment is to facilitate the student to create care plans based on a fictitious simulated patient. The purpose of the assignment is to critically analyse current evidence-based practice that support nursing care of actual and potential problems experienced by the patient requiring medical care needs.
Scenario for Care Plan
You take over the care of Mss Felicity who has been experiencing acute abdominal pain for the past 2 weeks and came to the Emergency Department (ED) as the pain became unbearable at home. she was transferred to your ward from ED having had an abdominal x ray, an ECG and blood analysis. He was given IV paracetamol in ED for the acute pain as her score was 8 on the Wong Baker pain assessment tool.
The following ISBAR 3 was used to handover the clinical care of Mss Felicity. When you have read the ISBAR 3 content, you are required to prepare 3 care plans for Mss Felicity. One care plan must be a pain care plan. You must use the guideline structure below and the ADPIE care plan template
Identify
ED nurse introduced herself as Nurse Mark, who had received care of Mss Felicity upon commencement of her shift in ED today.
Situation
Mss Felicity is currently scoring 3 on INEWS. His vital signs are as follows: RR is 22 breaths per minute, Oxygen Saturation is 96%, Blood Pressure is 115/75mmHg and HR is 105 BPM
Pain Score – patient reports a pain score of 8 in the right side of his abdomen. He was given IV paracetamol of 1 gram in ED and the pain score is now 7.
she was alert to person and place but very anxious and distressed.
Background
Mss Felicity a 75-year-old male, arrived to the ward accompanied by the ED nurse.
Mss Felicity has been experiencing acute abdominal pain for the past 2 weeks. He presented to the ED as the pain became unbearable at home. she has an abdominal x ray, an ECG and blood analysis done in ED. Results are still pending.
On review in ED the following information was elicited.
Acute right sided abdominal pain for the past 2 weeks.Unable to tolerate diet but can tolerate some fluids for theAppears very anxious and distressed. she is self -employed and has been unable to work for the past 2 weeks due to the painNo previous history of abdominal pain before this episode and no other medical conditionsshe smokes 20 cigarettes a day and drinks alcohol every dayshe is married and has 2 young childrenshe has noticed that she has lost a considerable amount of weight as herclothes are fitting loosely.she also states that her energy levels have reduced and complains of extreme tiredness.
Assessment
The medical impression is that Mss Felicity may have a duodenal ulcer but will require further investigations.Her ECG is normalHer pain score remains at 7 and he continues to be very anxious and distressed about being admitted to hospital and not been able to have a cigaretteHer INEWS remains at a score of 3It has been noted by the ED nurse, that he has lost some weight and that his clothes are fitting loosely.Medications – analgesics as required PRNUrinalysis – completed – dehydration markers noted
