First part of the scenario Carol Brady is 65-year-old female who has been admitted to your ward overnight, following a fall from a ladder while she was cleaning windows at home yesterday. She has a fracture to her left tibia and a laceration above her left eyebrow, which received four sutures in ED. Her husband witnessed the fall and reports there was brief LOC. Phx: GORD, HT, Migraines. You receive the following information during handover: Carol slept well intermittently overnight, waking with complaints of a headache and pain at # site. Analgesia was given by RN at 0400hrs. Dressing insitu above left brow and POP insitu left leg. We have not been able to assess her mobility as she has been sleeping most of the night and didn't want to disturb her. Q1. Describe the nursing assessments you would perform on Carol The second part of the scenario During your nursing assessment you find the following: That Carol has complaints of a headache and 8/10 pain at # site. On assessment, the left foot is pale, swollen with a faint pedal pulse. Vital signs: RR 24, SaO2 97, HR 90, BP 130/80, Temp 37.2 C. Q2.Identify the current pathophysiology in relation to the patient data. What is wrong with this patient? Q3.Develop a nursing care plan for this client. Choose one nursing diagnosis that is most relevant and important to this person's health problems. The NCP must include one nursing diagnosis, with one goal, three interventions relevant to the nursing diagnosis, and a rationale for each. For example: Nursing diagnosis: ________________________ related to _______________________________. Goal: The client will ___________________________ by______________________________. Intervention 1 (with rationale). Intervention 2 (with rationale). Intervention 3 (with rationale). Q4.You now need to hand over your findings to the doctor. Document your ISOBAR handover: · Identify · Situation · Observations · Background · Agree to a plan · Responsibility and risk management.
First part of the scenario
Carol Brady is 65-year-old female who has been admitted to your ward overnight, following a fall from a ladder while she was cleaning windows at home yesterday. She has a fracture to her left tibia and a laceration above her left eyebrow, which received four sutures in ED. Her husband witnessed the fall and reports there was brief LOC.
Phx: GORD, HT, Migraines.
You receive the following information during handover:
Carol slept well intermittently overnight, waking with complaints of a headache and pain at # site. Analgesia was given by RN at 0400hrs. Dressing insitu above left brow and POP insitu left leg. We have not been able to assess her mobility as she has been sleeping most of the night and didn't want to disturb her.
Q1. Describe the nursing assessments you would perform on Carol
The second part of the scenario
During your nursing assessment you find the following:
That Carol has complaints of a headache and 8/10 pain at # site. On assessment, the left foot is pale, swollen with a faint pedal pulse.
Vital signs: RR 24, SaO2 97, HR 90, BP 130/80, Temp 37.2 C.
Q2.Identify the current pathophysiology in relation to the patient data. What is wrong with this patient?
Q3.Develop a nursing care plan for this client. Choose one nursing diagnosis that is most relevant and important to this person's health problems. The NCP must include one nursing diagnosis, with one goal, three interventions relevant to the nursing diagnosis, and a rationale for each.
For example:
Nursing diagnosis: ________________________ related to _______________________________.
Goal: The client will ___________________________ by______________________________.
Intervention 1 (with rationale).
Intervention 2 (with rationale).
Intervention 3 (with rationale).
Q4.You now need to hand over your findings to the doctor. Document your ISOBAR handover:
· Identify
· Situation
· Observations
· Background
· Agree to a plan
· Responsibility and risk
management.
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