NR 509 Tina Jones Health History Care Plan Shadow Health.pdf Health Assessment for Practicing Nurses Health History Care Plan for Tina Jones

 

Course: NUR 353 - Health Assessment for Practicing Nurses Institution: West Coast University Session: January 2020

Patient: Tina Jones Assignment: Health History Care Plan Score: 100% (10 out of 10)

Student Performance Index:

 	
Status: Exhibits acute pain due to traumatic injury.
 	
Diagnosis: Acute pain (not chronic, as it began within the past week).
 	
Etiology: Pain related to traumatic injury (fall).
 	
Signs & Symptoms: Pain rated 7/10, with increased onset two days ago.




Performance Breakdown
Subjective Data Collection: Comprehensive gathering of Tina’s personal and medical history, symptoms, and lifestyle choices.

Objective Data Collection: Accurate clinical observations and physical examination findings.

Education and Empathy: Assessed the ability to educate Tina about her condition and treatment while demonstrating empathy.

Information Processing: Synthesis of collected data for informed clinical decision-making.

Documentation: Maintenance of detailed and precise records for effective healthcare delivery.

Care Plan: Developed and implemented a thorough care plan addressing Tina’s acute pain.



Detailed Sections
Nursing Diagnosis
Status: Tina’s condition is present (exhibits acute pain).

Diagnosis: Acute pain, based on Tina’s current pain rating and its persistence for the past two days.

Etiologies: Pain is related to the traumatic injury from a fall.

Signs & Symptoms: Pain onset two days ago, rated 7/10.



Care Plan
Short-Term Goal: To have Tina confirm verbally that her pain is reduced to an agreed-upon level (less than 4/10) within two hours.

Interventions:

 	
Administer pain medication as per provider order.
 	
Advise Tina to call for assistance with ambulation after taking opioid pain medication.
 	
Apply intermittent heat/cold packs on Tina’s right foot.
 	
Educate Tina on the side effects of pain medication.
 	
Encourage Tina to call for assistance if experiencing side effects and/or pain above 4/10.
 	
Provide distractions from pain through television, reading material, and/or music.
 	
Recommend intermittent repositioning, and encourage Tina to ask for help with changing positions.

Intervention Rationale:The interventions aim to manage Tina’s pain through both pharmacological and non-pharmacological methods. Educating Tina on medication side effects and involving her in her own care are essential for effective pain management.



Data Collection
Assess Pain Levels: Regularly ask Tina to rate her pain level after medication administration.

Monitor Side Effects: Inquire about any newly occurring side effects or non-pain symptoms.



Discussion and Evaluation
Goal Achievement: Within 90 minutes, Tina reported her pain was reduced to 2/10, achieving the goal of bringing her pain below 4/10 within two hours.



Communication and Consent

 	
Explain Diagnosis and Goals: Communicate the care plan to Tina, including the target pain rating and the interventions planned.
 	
Seek Consent: Obtain Tina’s consent to proceed with the interventions.
 	
Educate on Medication: Inform Tina about the pain medication and advise her to call for assistance with ambulation.

Feedback: Individual feedback from the instructor, if provided, will appear here.

Note: This care plan reflects the student’s performance in a simulated clinical environment using Shadow Health’s digital platform.