Using the Nanda 2015-2017 Nursing diagnosis definition and classification list..
Paul Smith is married and has 2 children. DOB 14/5/1976. He presented to the emergency department post ongoing abdominal pain with rebound tenderness. He has a history of hypercholesterolemia, heart murmur, smokes 15-20 cigarettes a day and drinks 3 beers daily. He lives on a farm 20km away from the hospital. He has been reviewed by the Surgeon and has been admitted to your ward for an Emergency Laparoscopic Appendectomy today. Please use intext referencing and reference Australian references only.
You have commenced your shift. You are required to read all of the documentation in Paul Smiths case file including: Nursing history and assessment form, Appendectomy clinical pathway, Pre-anaesthetic checklist (attached) And to complete the following tasks in consultation with the RN/assessor.
Question 1: Using the Nanda 2015-2017 Nursing diagnosis definition and classification list. (please see attached) Identify 1 actual and 2 potential (3 in total) nursing diagnoses using the domains of Nanda as listed below. Per each heading:
DOMAIN 3 – ELIMINATION AND EXCHANGE
DOMAIN 11 – SAFETY PROTECTION
DOMAIN 12 – COMFORT
Question 2: Using the information located on the Surgical Appendectomy Clinical pathway (MR107) and other documentation in Pauls file, such as the Nursing History and assessment form, complete the Country Health SA Patient care plan (MR-PCP) pages 2 and 4.
a) Page 2 – Under the heading Fundamentals of Care you are to identify and document the care needs required for Paul Smith Day 0 (preoperative) and include any interventions/diagnostic tests identified on the clinical pathway. (Document under other patient requirements)
b) Page 4 – Complete the dignity/respect/privacy, personal needs, psychological/social and environment requirement for Paul’s admission.
c) Using the information you have completed on the Surgical Appendectomy clinical pathway (MR107) and other documentation in Paul’s file such as the Nursing History and Assessment and the Country Health SA patient care plan (MR-PCP:
Identify 3 nursing interventions that you will undertake pre-operatively for Paul this shift.
Question 3: Explain the pathophysiology of Pauls presenting condition to Pauls wife, include clinical manifestations. (100 words) (You have already gained Pauls permission to share this information.)
Question 4: Paul has concerns about how he will care for himself immediately post operatively from the laparoscopic appendectomy. He asks you to explain the sorts of activities he will and won’t be able to undertake. Explain to Paul… 1 example of how the appendectomy may impact his ADLS (activities of daily living) /physical activities and how he can manage that example and
identify 1 psychological consideration that Paul may experience immediately post-surgery and a strategy to manage that consideration.
Question 5: You are to give Paul education on postoperative complications that he is most likely to experience due to his surgery. Identify from the list the two (2) most likely postoperative complications. Hypovolemic shock / Haemorrhage /Thrombophlebitis/Pneumonia