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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

• Direct Action: (of a nurse in conjunction with a doctors order)
• Direct Action: (of a nurse in conjunction with a doctors order)
• Direct Action: (of a nurse in conjunction with a doctors order)
• Direct Action: (of a nurse in conjunction with a doctors order)
• Referral:

Evaluation

Outcome

PROBLEM 2:risk of compartments syndrome

Rationale:

Intervention

• Direct Action: (of a nurse in conjunction with a doctors order)
• Direct Action: (of a nurse in conjunction with a doctors order)
• Direct Action: (of a nurse in conjunction with a doctors order)
• Direct Action: (of a nurse in conjunction with a doctors order)
• Referral:

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:

• Independent interventions – nurse led, nurse initiated
• Collaborative interventions – with other members of the multidisciplinary team
• Dependant interventions – for example dependant on a doctors order

The process to do this will involve:

Examination of assessment data:  assessment data can be either:

• Objective data: data which is empirical or which can be verified by an external source. Examples include: patient observations or lab tests.
• Subjective data: this is information which comes from the patient, family, or other sources and cannot be verified independently. An example is quality of pain described by patients (it is the patient’s perception of pain and cannot be verified by tests), patient descriptions about how they are feeling or a patient’s history told by the patient or family.

Organising the data:

• Group the assessment data,for example using Gordon’s Functional Health Patterns or an A-G style format may assist.
• After collecting both the subjective and objective data start to make connections between various assessment items and consider actual or potential health problems.
• Identify as many problems as you can for the patient then prioritise up to 6 problems that are the most immediate for this patient. This will form the basis of Assessment task 1.

Problems may be:

• an actual health problem: a health problem that is currently occurring and needs intervention to either end or reverse its effects. Patient signs and symptoms support the manifestation of the problem.

Examples:           Anxiety related to…..

Dehydration due to ……..

Infection related to ……

Pain related to ….

Impaired skin integrity due to ….

• a potential health problem: a health problem which has not yet occurred, however based on assessment items is likely to occur if no intervention or prevention is initiated within a short period of time. The patient is ‘at risk of’.

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.

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.