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Name of patient: |
Scenario situation number: 2B |
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List the cluster of cues related to one priority problem in the identified scenario situation. Clearly indicate which cues are abnormal and provide the normal ranges (with referencing) for comparison where appropriate. The respiration rate that has been observed in patient is 22 which is considered as normal. Level of oxygen saturation shows little deficiency which should be maintained between 95 to 100%. Actual value that found in this patients case is 92% in 2 litre of oxygen. Pulse rate also shows normality in its figure. On the other hand, blood pressure is on lower side which should be maintained 120/80 in healthy individuals. Pain score is observed to be quite high. BGL 14.2 indicates a mild high in blood sugar level which should be 7.8 after 2 hours of having a meal. Body temperature was lower than the usual which 35.8 are. According to Ackley et al. (2019), when patient is unable to take deep breath it indicates presence of some serious shallow breathing problem. Urine has been measured as 15 ml per day. He was feeling nauseated means there may be an issue of gastrointestinal. Dehydration may also occur as lips are getting dry unnecessarily. Alteration or changes in fluid balance can be linked with postoperative fluid loss, poor oral intake, fasting, bowel preparation and others. On the other hand, fluid volume deficit or hypovolema can occur from in taking of IV fluid of insufficient amount. Gaseous exchange was also observed abnormal for the patient. PCA or patient controlled analgesia reports shows no notable abnormality. On auscultation, presence of bowel sound confirms presence of some gastrointestinal abnormalities. Presence of slight pinkness around medical incision is quite normal after a surgery. There was also oozing out of scant haemoserous observed in dressing area. This is quite natural in this case and need not to worry. |
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Process information - Pathophysiology: Discuss abnormalities in relation to the associated risk factors and pathophysiological processing occurring From analysis of above factors following abnormalities can be predicted. As in pulse rate or oxygen saturation level no abnormality found, it can be predicted that there may not have any cardiac problem. Drying of lips indicates presence of dehydration. Whereas, other symptoms like occasional hearing of occasional bowel sounds and presence of nausea indicates some serious issue. The serious issue may be related to post surgical wounds or some additional gastrointestinal problems. After a surgical procedure it takes a little bit time for patients to recover. This situation further complicates when there is a high blood glucose level. Presence of mild but higher level of blood glucose hinders the healing process of surgical wounds. Hence, haemo-serous materials are observed to ooze out from dressing. Gulanick & Myers (2016) comment a post surgical healing generally occurs in four overlapping stages. The first step includes homeostasis, which is followed by inflammatory or defensive phase. The third phase includes proliferative phase and last stage termed as maturation phase. These usually occur in a normal condition. Along with low blood pressure of about 90/60 and mild high blood glucose level, healing procedures take a bit of time. Patient centred analgesia showed no notable abnormalities in this case. |
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Actual nursing diagnosis with related to and evidenced by statements |
Goal of care including SMART outcome criteria |
Priority Nursing actions (4) including specific detail |
Rationales for actions clearly explained with in text reference |
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The term nursing diagnosis refers to a medical judgement in regard to a person, community or family responses to potential or actual health issues (Wang et al. 2015). The specific nurse remains accountable for achieving outcomes from their nursing interventions. It includes potential risk or wellness responsible to health issues faced by the patients. Inflammatory or viral processes may result from ineffective or irregularities in breathing patterns. Trachea-bronchial obstructions may also occur from non-deep breath on command. Socio economic status of patients may also hamper due to anxiety generated from alteration in routines and environment. Alteration in situational crisis or health status can also be a potent cause of anxiety. Disturbances related to body image have been appeared due to presence of temporarily visible tube or Bolovac drain. Rationale: enhanced pain due to post-operative wounds and increased anxiety due to alteration in health status. |
The goal of this nursing care plan is to determine measures to resolve, reduce or prevent verified problems of client. A SMART outcome criterion has been given below in order to set an effective patient treatment plan. The plan of care is mainly “to heal post operative wounds and bodily dysfunctions faster”. Specific: To identify and view appropriate nursing interventions and medications and tackle dysfunctions better and make ease to patient’s physical condition. Measurable: This particular goal is understandable, precise, clear and straight forward through measurement of vital signs of the patient. Attainable: Regular investigations of symptoms and signs and recording them properly in order to implicate nursing interventions and proper medication can make this recommendation attainable. Realistic: Signs and symptoms of patent’s medical conditions can be recorded efficiently. Hence it is realistic Time: The nursing goal can be attained within 2 weeks of time period as post-operative wounds need time to be cured.
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Nurses must regulate a proper diet and medications so that blood glucose level remains constrained. Regular and periodic ooze dressing of the surgically wounded area of pink coloured is necessary to avoid risk of infection. In case of signalling of any serious emergency nurse must call for respective physician to look into that matter effectively. Nurse must be aware of problems regarding non tolerating oral nausea and dehydration. As per Munshi et al. (2016), they should take measures to keep patient hydrated in regular interval of time. Nurses ask patients to take deep breathing in order to check for any respiratory abnormalities. Drinking of adequate water must be maintained by respective nurses. They should also ensure that patient is urinating properly. Nurses must take care of pain and try to soothe it by giving pain killers with consultation to a physician. Nurses are obliged to take special care for post surgical patients. They have responsibility to monitor patient’s vital signs. On basis of health conditions, nurses can suggest patients to get up and move. This is to ensure that their blood circulation can be proper.
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In case of inpatient surgery, nurses are trained to take specialised and particulate care for respective patients. In this case scenario, patient was observed to have high pulse rate which is 116 and respiratory rate. On other hand, a mild hike in blood glucose level and pain. Nurses must give pain relievers to that patient so that he can get relief. The rationale for this action is that the pain reliever can reduce stress and trauma in the patient. After a surgery patients body needs rest both physically and mentally. Hence the feeling of intense pain may divert their recovery procedures (Drossman, 2016). The rationale for pain diversion is to increase the comfort and deliver a patient-centred care. In order to recover fast, painkillers or relievers are used which interfere with nerve pain messages to be delivered to brain of patients. Hence they do not realize feeling of pain. In this mean time, their body can recover. Patient must be keep hydrated by giving intravenous saline water. The rationale for hydrating the patient is to maintain his osmotic balance. As patient have no will no intake water orally. He must be provided saline water through channels (Coulter et al. 2015). It will automatically keep him hydrated. Dressing in regular interval would prevent wound to get infected. Dressing maintains an optimum pH level and temperature to escalating healing procedures. It also maintains wounds free from contaminants or even cross contaminations from other patients.
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Name of patient: |
Scenario situation number |
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List the cluster of cues related to one priority problem in the identified scenario situation. Clearly indicate which cues are abnormal and provide the normal ranges (with referencing) for comparison where appropriate. |
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Process information - Pathophysiology: Discuss abnormalities in relation to the associated risk factors and pathophysiological processing occurring |
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Actual nursing diagnosis with related to and evidenced by statements |
Goal of care including SMART outcome criteria |
Priority Nursing actions (4) including specific detail |
Rationales for actions clearly explained with in text reference |
Care Plan Assessment Type Written Assignment
Purpose- This assignment is designed for students to consolidate their learning in the first three (3) tutorials; to demonstrate their clinical reasoning and application of the Clinical Reasoning Cycle to identify and process cues, identify priority patient centred nursing diagnoses, set specific, measurable, achievable, realistic and timely goals and plan appropriate nursing actions with rationales based and scientific and best practice nursing literature.
Your assessment reveals the following:
RR 22 and shallow, chest clear, oxygen saturation 92% on 2L oxygen via nasal prongs, P 116, BP 90/60, T 35.8, pain score 8/10, BGL 14.2. His urine output for the previous hour is 15mL. He is not able to take a deep breath on command. He says he feels nauseated and has not been able to tolerate more than a few sips of water. His lips and tongue look dry. When you check his PCA history you note that there have been no recent demands recorded.
His abdomen is slightly distended and firm, occasional bowel sound on auscultation. The area around the midline incision is slightly pink, and there is scant haemo-serous ooze on the dressing, and minimal haemo-serous drainage in the Belovac.
MARKING GUIDE
Appendix 1: Assessment item 1 - Care plan
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Chosen scenario to be used is identified |
0 The scenario is not identified |
1 The chosen scenario is clearly identified at the beginning of the assignment |
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A cluster of cues has been listed, abnormalities identified and compared to normal values |
0 Cues cluster not listed |
1 Some of the cues are listed, but a number are missed, or irrelevant cues included |
2 Most of the cues are listed and abnormalities identified |
3 All the relevant cues are listed and compared to normal values with referencing |
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The related risk factors and pathophysiology is discussed |
0-2 The risk factors and pathophysiology are not discussed or are discussed at a very superficial or inaccurate level |
3-4 The risk factors and pathophysiology are discussed at a beginning level, or is not clear or fully accurate. There is no or limited link to the abnormal cues |
5-6 The risk factors and pathophysiology are adequately discussed, supported by reference to source material, and linked to abnormal cues |
7 The risk factors and pathophysiology are clearly explained, supported by reference to source material, and well linked to abnormal cues |
8 The related risk factors and pathophysiology are clearly explained showing an in-depth understanding, supported by reference to quality source material, and well linked to the abnormal cues. |
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Actual Nursing Diagnosis/ problem identified with associated related to and evidenced by statements |
0 There is no identified nursing diagnosis/problem, or the problem identified is not a priority |
1 A priority nursing diagnosis is identified but is poor expressed or there are no related to and evidenced by statements |
2 A priority nursing diagnosis is identified and there is an attempt to include related to and evidenced by statements |
3 A priority nursing diagnosis is identified and clearly written with clear related to and evidenced by statements |
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A clear goal is identified to address the problem with set outcome measures that meet SMART criteria |
0 There is no goal or the goal is not relevant to the identified problem |
1 There is a relevant goal but no specific outcome measures |
2 There is a relevant goal with some outcome measures |
3 There is a relevant goal with clear outcome measure that meet most SMART criteria |
4 There is a relevant, clearly written goal with detailed outcome measures that meet all SMART criteria |
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Four priority nursing actions are provided with detail |
0-3 There are less than four nursing actions, or the actions are not relevant to the identified problem |
4-5 There are four relevant nursing actions identified but with limited detail |
6 Four relevant nursing actions are provided with adequate detail |
7 Four relevant nursing actions are provided that include adequate detail and address the highest priority actions required for the situation |
8 Four relevant, well detailed, high priority nursing actions are well explained. |
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A rationale is provided for each action that is supported with a reference to scientific, nursing or related literature |
0-3 A rationale is not provided for each action or the rationales are not relevant or not referenced |
4-5 A rationale is provided for each action, and most are relevant and referenced |
6 An adequate rationale is provided for each action and each is referenced to appropriate literature |
7 A clear rationale is provided for each action and referenced to quality literature |
8 A well written rationale that shows in-depth understanding is provided for each action, and each is referenced to quality literature |
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A reference list is provided that meets APA requirements. The assignment meets School standards in relation to literacy and academic integrity |
0 Reference list not provided, or more than 10% direct quotations, or significant unacknowledged direct source material, or very poor literacy making reading very difficult. |
1-2 Significant APA referencing errors in reference list or text, or significant spelling and grammatical errors throughout the assignment. Limited or poor source material used |
3 Minor APA referencing errors in reference list or text, minor spelling or grammatical errors. Adequate source material used |
4 Well written and correctly referenced throughout. A good range of source material used. |
5 Outstanding presentation. Well written and correctly referenced throughout. An excellent range of source material well utilized in discussion. |
Totalmark out of 40:
Final mark out of 20:
