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Tina Jones Health History Care Plan Shadow Health.pdf
Physical assessment (NURS 190)
West Coast University
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Health History Results | Turned In
Health Assessment for Practicing Nurses - January 2020, NUR 353
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Care Plan : 10 of 10 (100%)
Nursing Diagnoses: Definitions & Classifications 2018-2020 © NANDA-International, 2017 used by arrangement with Thieme Medical Publishers, Inc., a division of the Thieme Group. All rights reserved. Authorized translation from the English language edition published by Thieme Medican Publishers Inc. No part of this material may be reproduced in any form without the written permission of the agent of the copyright holder, NANDA-International. Direct inquires to nanda-i@thieme. Link for more information: nanda/.
Status
Student Response Model Answer Explanation Points Earne
exhibits exhibits The correct status for the nursing diagnosis is "exhibits," because Ms. Jones's condition is not a risk but is present.
0 out of 0.
Diagnosis
Student Response Model Answer Explanation Points Earne
acute pain acute pain While Ms. Jones does exhibit deficient knowledge in some healthcare areas, her most pressing need for you to address is her pain. Chronic pain is usually defined as pain lasting more than 12 weeks; because Ms. Jones's pain began within the past week, her diagnosis is acute pain.
0 out of 0.
Etiologies
Student Response Model Answer Explanation Points Earne
traumatic injury traumatic injury Ms. Jones's pain is located at the wound she received by falling, so her pain is related to that traumatic injury.
0 out of 0.
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Overview
Transcript
Subjective Data Collection
Objective Data Collection
Education & Empathy
Documentation
Care Plan
Health History Tips and Tricks
Hallway
Self-Reflection
Nursing Diagnosis 2 out of 2
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Signs & Symptoms
Student Response Model Answer Explanation Points Earne
pain increase onset: 2 days ago pain increase onset: 2 days ago Pain is subjective and can only truly be evidenced by a patient's verbalizing it, so Ms. Jones's reported 7/10 pain rating informs her diagnosis of acute pain. In addition, her pain began a week ago and shot up 2 days ago, indicating the timeline needed for pain to be called "acute."
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pain rating of 7/10 pain rating of 7/10 Pain is subjective and can only truly be evidenced by a patient's verbalizing it, so Ms. Jones's reported 7/10 pain rating informs her diagnosis of acute pain. In addition, her pain began a week ago and shot up 2 days ago, indicating the timeline needed for pain to be called "acute."
0 out of 0.
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
Why is pain a more urgent issue to address than a patient's deficient knowlege?
Pain is getting in her way of doing regular activities in her life like walking. Also with a patient that is in pain would have a hard time leaning ways to improve her health so first getting rid of the pain and than adressing her knowlege deficient would be affective.
While patient teaching is a helpful tool for benefiting a patient's long-term health, pain debilitates a patient right now, and you have a duty to make your patients feel comfortable and as pain-free as possible.
Always consider timing when choosing between two valid diagnoses; issues that may arise in the future should only addressed once currently ongoing issues have been resolved.
Short-Term Goal
Student Response Model Answer Explanation Points Earne
To have patient confirm verbally that pain is brought down to an agreed- upon pain level (less than 4/10) within two hours.
To have patient confirm verbally that pain is brought down to an agreed- upon pain level (less than 4/10) within two hours.
While diabetes teaching is important, your diagnosis is "acute pain," and so teaching should be saved for when the pain is managed. In addition, while coping with pain can be an effective mental strategy, you have the power to reduce the pain itself. Note that it is not enough for a goal to be "reduce a patient's pain;" for the sake of your patient's comfort, you should strive to reduce pain within a short time frame, and with a low target pain rating that the patient agrees to.
0 out of 0.
Self Assessment
Planning 5 out of 5
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Provide distraction from pain through television, reading material, and/or music
Provide distraction from pain through television, reading material, and/or music
A complete care plan involves both pharmacological and non- pharmacological treatments, when possible. You should encourage the patient to be involved in their own interventions, such as asking for help ambulating or repositioning when doing so alone could be dangerous. Your education for the patient should also be limited to the interventions at hand, like medication side effects; diabetes teaching should be saved for when the patient is more comfortable.
0 out of 0.
Recommend intermittent repositioning, and encourage patient to ask for help with changing position
Recommend intermittent repositioning, and encourage patient to ask for help with changing position
A complete care plan involves both pharmacological and non- pharmacological treatments, when possible. You should encourage the patient to be involved in their own interventions, such as asking for help ambulating or repositioning when doing so alone could be dangerous. Your education for the patient should also be limited to the interventions at hand, like medication side effects; diabetes teaching should be saved for when the patient is more comfortable.
0 out of 0.
Intervention Rationale
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
In 1 or 2 sentences, explain how your selected interventions work to accomplish your goal.
The interventions are related to manage the goal of reduing pain for the patient. This includes pain management, explaing side effects of medications and calling for help when needed for pain reduction.
Pain medication, in combination with an array of non- pharmacological pain reductions, have the power to drastically reduce your patient's pain and make them comfortable. You're also teaching the patient coping strategies that they can use at home, like hot and cold packs, shifting positions, and distraction through TV or reading.
Even with pain medication, pa can be difficult to reduce, so it important to approach it from a many angles as possible, both for the patient's immediate comfort and to teach them valuable pain-reduction habits
Data Collections
Student Response Model Answer Explanation Points Earne
Ask patient about pain-level rating after medication administration
Ask patient about pain-level rating after medication administration
It is not enough to administer pain medication and pain coping methods; their success may vary, so you should ask your patient herself to verbalize her pain rating. In addition, you should ask if your patient is experiencing non-pain symptoms; pain medication can cause unpleasant side effects, and Tina's foot wound has caused her non-pain symptoms.
0 out of 0.
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Ask patient about newly occurring side effects and/or non-pain symptoms
Ask patient about newly occurring side effects and/or non-pain symptoms
It is not enough to administer pain medication and pain coping methods; their success may vary, so you should ask your patient herself to verbalize her pain rating. In addition, you should ask if your patient is experiencing non-pain symptoms; pain medication can cause unpleasant side effects, and Tina's foot wound has caused her non-pain symptoms.
0 out of 0.
Your answer is not automatically evaluated by the simulation, but may be reviewed by your instructor.
Prompt Student Response Model Answer Explanation
Explain the rationale behind your nursing diagnosis.
Ms Jones first we want to treat your pain and get it down to a 4 out of 10
It won't come as any surprise that I'm diagnosing you with acute pain related to your traumatic injury, based on your current pain rating and its persistence for the past two days.
A patient should understand their nursing diagnosis and the rationale behind it to increase their sense of involvement and to identify areas for future improvement.
Explain your goal for Ms. Jones, including the target pain rating, and the interventions and data collections you will use.
We want your pain to be 4 out of 10 and will give pain medications to help reach that goal.
My goal for you is that within two hours, we can get your pain down enough for you to report it below a 4 out of 10, if that sounds appropriate to you. We're going to re-administer the pain medication we administered earlier, which may affect your coordination, so make sure to ask us with help walking around. Let's also try some non-medication therapy: hot and cold packs for your foot, taking your mind off it through books, TV, etc., and shifting positions every so often, which you can ask us for help with. We're going to remind you of the side effects of the medication as well, so let us know if you experience any, or if your pain doesn't budge below a 4.
You should communicate the Care Plan to the patient, allowing them to have involvement and agency in the own healthcare.
Explicitly ask for Ms. Jones's consent to the Care Plan.
Do you agree with this plan. Do I have your consent to move forward with these interventions?
A patient must consent to all interventions in their Care Pla Disagreements are opportunit to provide further patient education and to consider alternative options.
Inform Ms. Jones you will now educate about and administer her pain medication.
We will give you pain medication so please call for assistance when you want to get out of be or ambulation.
Unless you have any other questions, I will now administer your pain medication and educate you on it.
It's time to begin your educatio interventions, so let your patie know!
Discussion Of Care
Intervention & Evaluation 2 out of 2
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Tina Jones Health History Care Plan Shadow Health.pdf
Course: Physical assessment (NURS 190)
University: West Coast University
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