Assignment Task

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 utilizing nursing diagnosis and nursing interventions.

Aim of Assignment

The aim of this assignment is to facilitate the student in creating care plans based on a fictitious simulated patient. The purpose of the assignment is to critically analyze current evidence-based practices that support the 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 Ms. 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 after having an abdominal X-ray, an ECG, and blood analysis. She 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 hand over the clinical care of Ms. Felicity. When you have read the ISBAR 3 content, you are required to prepare 3 care plans for Ms. Felicity. One care plan must be a pain care plan. You must use the guideline structure below and the ADPIE care plan template.

Identify

The ED nurse introduced herself as Nurse Mark, who had received care of Ms. Felicity upon commencement of her shift in ED today.

Situation

Ms. Felicity is currently scoring 3 on INEWS. Her 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 – the patient reports a pain score of 8 in the right side of her abdomen. She 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

Ms. Felicity, a 75-year-old female, arrived on the ward accompanied by the ED nurse.

Ms. Felicity has been experiencing acute abdominal pain for the past 2 weeks. She presented to the ED as the pain became unbearable at home. She has had 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.
• Appears very anxious and distressed. She is self-employed and has been unable to work for the past 2 weeks due to the pain.
• No previous history of abdominal pain before this episode and no other medical conditions.
• She smokes 20 cigarettes a day and drinks alcohol every day.
• She is married and has 2 young children.
• She has noticed that she has lost a considerable amount of weight as her clothes are fitting loosely. She also states that her energy levels have reduced and she complains of extreme tiredness.

Assessment

The medical impression is that Ms. Felicity may have a duodenal ulcer but will require further investigations.

• Her ECG is normal.
• Her pain score remains at 7 and she continues to be very anxious and distressed about being admitted to the hospital and not being able to have a cigarette.
• Her INEWS remains at a score of 3.
• It has been noted by the ED nurse that she has lost some weight and that her clothes are fitting loosely.
• Medications: analgesics as required PRN.
• Urinalysis: completed – dehydration markers noted.