Ben is a 38-year old male and was brought into the ED due to a major road traffic accident and required urgent open reduction internal fixations for both his left femoral fracture and left tibial fracture. Considering Ben’s blood test result and present situation, it is believed that Post operatively, Ben’s one of actual problem is Anaemic and the potential problem is at risk of compartments syndrome.
PROBLEM 1:
Rationale:
Intervention
Evaluation
Outcome
PROBLEM 2:risk of compartments syndrome
Rationale:
Intervention
Evaluation
Outcome
COMPLEX NURSING CARE – MEDICAL/SURGICAL
ADDITIONAL GUIDELINES
ASSESSMENTTASKS1 AND 2
PLEASE READ THE DESCRIPTION OF THE ASSESSMENT ITEMS IN THE SUBJECT OUTLINE or in UTSOnline IN CONJUNCTION WITH THESE ADDITIONAL NOTES
Assessment 1 – Complex Patient Care Plan
Focus on patient assessment data, problem identification and optimal patient outcomes
Patient problem identification
Use the principles of the nursing process and the assessment data from one of two case studies (Ben Casey Part 1 or Peter Lars) to identify actual or potential health problems which can be dealt with using nursing interventions. Nursing interventions can be:
The process to do this will involve:
Examination of assessment data: assessment data can be either:
Organising the data:
Problems may be:
Examples: Anxiety related to…..
Dehydration due to ……..
Infection related to ……
Pain related to ….
Impaired skin integrity due to ….
At risk of falls due to …
At risk for DVT due to….
Once the actual or potential health problems are identified, the patient and/or nursing outcomes need to be considered. The outcome, like the problem, needs to be of a patient or nursing nature. This means that the intervention should be one that a Registered Nurse can perform/is involved with. The nursing outcomes (dot points) describe whatnursing interventions expect to achieve for the patient.
Focus on those problems and nursing/patient outcomes that nursing interventions could contribute to or could be completed during one standard nursing shift.
Actual or potential problem | Assessment data | Nursing outcome |
Actual problem: the patient is dehydrated related to decreased fluid intake | Low blood pressure (or ↓BP)Tachycardic
Patient states he is thirsty |
Patient will return to a normotensive state as evidenced by higher blood pressure, stable andacceptable pulse, and a lack of reported thirst |
Note: you can use common abbreviations or symbols, e.g. BP for blood pressure,↓ for decrease.
List 1 key reference, policy or guidelines for each problem identified that has informed your care plan. List these as a bibliography – they do not need to be cited in the care plan. These need to be nursing/professionally oriented sources not, for example, patient/consumer websites.