Case Study

May 4, 2022

Dorothea Orem Theory Case Study

May 4, 2022

ER Patient Assessment And Clinical Log For MSN

PAGE

Kingdom of Saudi Arabia

Ministry of Education

University of Hail

College of Nursing

المملكة العربية السعودية

وزارة التعليم

جامـعـة حـائل

كلية التمريض

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)

Student Name
Student ID
Date
Hospital
Instructor Name

Patients Data
Patient’s name (First & surname):
Healthcare Record Number (HRN):
Age:
Gender:
Presenting Chief complaint:
Triage category:
Infection status:
Accompanied by:
Source of data collection/gathering	FORMCHECKBOX Patient FORMCHECKBOX Family or significant other FORMCHECKBOX Caregiver FORMCHECKBOX EMS personnel FORMCHECKBOX Bystander FORMCHECKBOX Use of translator
Medical Diagnosis:
Last oral intake:

Mechanism of injury (if any)

Types of Injuries (if any)

FORMCHECKBOX Blast Forces (Explosions)

Blunt Forces

FORMCHECKBOX A. motor vehicle collisions,

FORMCHECKBOX B. automobile versus pedestrian collisions

FORMCHECKBOX C. motorcycle collisions,

FORMCHECKBOX D. sports-related activities,

FORMCHECKBOX E. falls

Penetrating Forces

FORMCHECKBOX A. Stab wounds

FORMCHECKBOX B. Gunshot wounds

Type of Energy caused Injury/Trauma

FORMCHECKBOX Mechanical energy

FORMCHECKBOX Thermal energy

FORMCHECKBOX Electrical energy

FORMCHECKBOX Chemical energy

Effected Organ of the Injury/Trauma

Trauma Score (Refer to Revised Trauma Score Appendix)

Summary of the Primary Assessment:

List all abnormalities based on primary assessment (refer to Primary Assessment Guidelines)

History of Present Illness/injury/chief complaint (Repeat this table for each of the symptoms)
Palliative Factors
Provocative Factors
Quality
Region
Radiation
Severity
Timing: Onset
Timing: Duration
Timing: Frequency
Treatment prior to arrival

Pathophysiology of the Disease/ Patient condition/ Medical Diagnosis

Full Set of Vital Signs

Time

Blood Pressure

Temperature

Central & Peripheral Pulse

SpO2

GCS

Pain Severity

Location

Value

MAP

Route

Value

Location

Rate

Rhythm

Quality

Diagnostic Examinations/Procedures:

(Include Blood type, Lactate, ABGS, ECG, CTCO2, Lab Tests, radiographic studies, etc…)

Test/Procedure

Reference Value

(Normal Results)

Patient Results

Nursing Considerations

Pain Assessment
Palliative Factors
Provocative Factors
Quality
Region
Radiation
Severity*
Timing: Onset
Timing: Duration
Timing: Frequency
* Pain Scale used for severity assessment: FORMCHECKBOX FACES pain rating scale for patients approximately 3 years of age and older FORMCHECKBOX Visual analog scale for school-age children and adolescents FORMCHECKBOX FLACC (Faces, Legs, Arms, Cry, Consolability) Scale for infants and preverbal children FORMCHECKBOX Numeric rating scale for older school-age children and adolescents

Past Medical History
Patient’s definition of own health
past medical history (PMH), to include hospitalization/ surgeries:
Current or preexisting diseases/illness/injuries/surgeries	FORMCHECKBOX Respiratory disease FORMCHECKBOX Cardiovascular disease; risk factors FORMCHECKBOX Neurologic disease FORMCHECKBOX Endocrine disease FORMCHECKBOX Hepatic disease	FORMCHECKBOX Infectious disease FORMCHECKBOX Hematologic disease FORMCHECKBOX Immunosuppression FORMCHECKBOX Autoimmune disease FORMCHECKBOX Psychological disorders psychiatric or mental health FORMCHECKBOX Others, Specify:
Allergies	FORMCHECKBOX Medication—prescription, OTC FORMCHECKBOX Food/beverages FORMCHECKBOX Latex FORMCHECKBOX Iodine FORMCHECKBOX Environmental
Immunization status	FORMCHECKBOX Pneumococci FORMCHECKBOX Influenza FORMCHECKBOX Tetanus FORMCHECKBOX Childhood illnesses
Psychological/social/environmental factors
FORMCHECKBOX Smoking:
FORMCHECKBOX Substance and/or alcohol use/abuse:
Safety	FORMCHECKBOX Possible/actual assault, abuse, or intimate partner violence situations FORMCHECKBOX Use of seat belts FORMCHECKBOX Texting while driving FORMCHECKBOX Drinking and driving
Psychiatric history (personal or family members):
Literacy (level of Education)
Behavior appropriate for age and developmental stage:
Occupation/profession:
Meaning of illness, injury, or event to patient/family:
Patient’s/family’s expectations of care:
Support system:	FORMCHECKBOX Family structure FORMCHECKBOX Significant others FORMCHECKBOX Social agencies FORMCHECKBOX Religious affiliation FORMCHECKBOX Caregivers
Responsibilities	FORMCHECKBOX Self FORMCHECKBOX Family FORMCHECKBOX Business FORMCHECKBOX Community
Cultural beliefs and practices:
Spirituality:
Living accommodations	FORMCHECKBOX House FORMCHECKBOX Apartment FORMCHECKBOX Accessibility (e.g., stairs) FORMCHECKBOX Homeless, shelters
Affordability and accessibility to care—socioeconomic status:
History of descriptive and non-descriptive medications:
Descriptive medications (Prescribed by physician/doctor):
Generic Name & / Classification	Trade Name	Dosage	Frequency	Route



*Non-descriptive medications: Legal/ illegal, over the counter drugs (OTC):*
Generic Name & /Classification	Trade Name	Frequency	Route	Rationale

Head-to-Toe Assessment (Review of Systems)

Describe only abnormal findings: Refer to Chapter one (Nursing Assessment and Resuscitation)

General appearance

Skin/mucous membranes/nail beds

Head and face

Eyes/ Ear/ Nose/ Mouth/ Neck

Chest

Abdomen/flanks

Pelvis/perineum

Extremities

Posterior Surfaces

Currently Described Medications

Generic Name

(Dosage, Route, Frequency)

Trade Name/

Classification

Adverse Reactions

Nursing Responsibilities

Treatments/Therapeutic Regimens/Doctor Orders rather than Medications

(e.g. oxygenation, ventilation, intubation, cardioversion, IV therapy, etc.)

NURSING CARE PLAN

(Provide 3 Nursing Diagnosis and write one Nursing Diagnosis per Page)

Assessment

Priority Nursing Diagnosis

Planning

Nursing intervention

Rationale

Evaluation

Subjective Data: What the client says about this problem

Statement of Problem (Nursing diagnosis from NANDA list)

R/T: Related to (Etiology)

AEB: As Evidenced by (supportive S & O Data)

Goal: To (General statement reverse the statement of problem)

Objectives: Patient will (specific statement define what will be observed when the goal is met which is measurable & provide time frame)

Short Term Goal (achievable within hours to day)

Long Term Goal (achievable within days, weeks, or month)

Could be

1. Re-assessment (to look for improvement and prevent complications)

2. Independent (can be implemented without doctor order)

3. Dependent (based on doctor order)

4. Collaborative (together with other health care providers such as nutritionist, physical therapist)

Scientific principles, theories or concepts underlying nursing

Interventions to tell why each intervention

should help achieve the

goal

Must have statement for each action

Give specific text

references for each

intervention (name

of text and page

number).

Be sure to attach a

bibliography.

Evaluation of

Goals:

Write a summary statement

of each goal (the

goal met, partially me or non-met), Evaluation of Objectives:

write specific statement for each objective define what is observed, give measurement and specific date and time, describe how the patient looks, feels or behaves after nursing interventions have been implemented.

Objective Data:

What you observe:

see, hear, feel, smell, and measure + Client lab values, test Results + Medications + Doctor’s diagnosis from patient chart

Assessment

Priority Nursing Diagnosis

Planning

Nursing intervention

Rationale

Evaluation

Subjective Data: What the client says about this problem

Statement of Problem (Nursing diagnosis from NANDA list)

R/T: Related to (Etiology)

AEB: As Evidenced by (supportive S & O Data)

Goal: To (General statement reverse the statement of problem)

Objectives: Patient will (specific statement define what will be observed when the goal is met which is measurable & provide time frame)

Short Term Goal (achievable within hours to day)

Long Term Goal (achievable within days, weeks, or month)

Could be

1. Re-assessment (to look for improvement and prevent complications)

2. Independent (can be implemented without doctor order)

3. Dependent (based on doctor order)

4. Collaborative (together with other health care providers such as nutritionist, physical therapist)

Scientific principles, theories or concepts underlying nursing

Interventions to tell why each intervention

should help achieve the

goal

Must have statement for each action

Give specific text

references for each

intervention (name

of text and page

number).

Be sure to attach a

bibliography.

Evaluation of

Goals:

Write a summary statement

of each goal (the

goal met, partially me or non-met), Evaluation of Objectives:

Objective Data:

What you observe:

see, hear, feel, smell, and measure + Client lab values, test Results + Medications + Doctor’s diagnosis from patient chart

Assessment

Priority Nursing Diagnosis

Planning

Nursing intervention

Rationale

Evaluation

Subjective Data: What the client says about this problem

Statement of Problem (Nursing diagnosis from NANDA list)

R/T: Related to (Etiology)

AEB: As Evidenced by (supportive S & O Data)

Goal: To (General statement reverse the statement of problem)

Objectives: Patient will (specific statement define what will be observed when the goal is met which is measurable & provide time frame)

Short Term Goal (achievable within hours to day)

Long Term Goal (achievable within days, weeks, or month)

Could be

1. Re-assessment (to look for improvement and prevent complications)

2. Independent (can be implemented without doctor order)

3. Dependent (based on doctor order)

4. Collaborative (together with other health care providers such as nutritionist, physical therapist)

Scientific principles, theories or concepts underlying nursing

Interventions to tell why each intervention

should help achieve the

goal

Must have statement for each action

Give specific text

references for each

intervention (name

of text and page

number).

Be sure to attach a

bibliography.

Evaluation of

Goals:

Write a summary statement

of each goal (the

goal met, partially me or non-met), Evaluation of Objectives:

Objective Data:

What you observe:

see, hear, feel, smell, and measure + Client lab values, test Results + Medications + Doctor’s diagnosis from patient chart

References

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