NR 509 Tina Jones Health History Care Plan Shadow Health.pdf

15 July 2024

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:

  1. Administer pain medication as per provider order.
  2. Advise Tina to call for assistance with ambulation after taking opioid pain medication.
  3. Apply intermittent heat/cold packs on Tina’s right foot.
  4. Educate Tina on the side effects of pain medication.
  5. Encourage Tina to call for assistance if experiencing side effects and/or pain above 4/10.
  6. Provide distractions from pain through television, reading material, and/or music.
  7. 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.

  1. Explain Diagnosis and Goals: Communicate the care plan to Tina, including the target pain rating and the interventions planned.
  2. Seek Consent: Obtain Tina’s consent to proceed with the interventions.
  3. 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.