Stimulation scenario: –
Mr bright is feeling nauseated and wanted to sit upright however he can only rise 30 degree. The shift planner requires
• Blood sugar needs to be measured.
• Vitals needs to be monitored
• He also mentioned that he is feeling hot, due to fever caused after the surgery= the temperature needs to be checked and a bed sponge needs to be given.
• Chest pain caused due to the after effect. Mr Bright says that the pain is radiating towards the jaws: – Vasoconstrictor Morphine is being administered as prescribed to relief the pain.
• BP to be checked every 10-15 mins.
• Slight increase in the Heart rate.
• Medication to minimise the nausea can be administered as prescribed
Correct nursing assessment performed: (JUSTIFICATION NEEDS TO BE PROVIDED) the assessment need to be linked to tissue perfusion and haematoma formation
• Introduction of the team to the patient was goo
• ABCD was checked,
• Vascular circulation done
• The ob.’s was monitored
• Position maintained @ 30degree
• Meds was prepared to manage pain
• Communication was good
• Good team work
Nursing assessment not performed: (JUSTIFICATION NEEDS TO BE PROVIDED) the assessment need to be linked to tissue perfusion and haematoma formation
• Chest pain monitoring
• ABCD wasn’t followed in a correct pattern
• Head to toe examination wasn’t effective
• PQRST pain assessment was not done
• Ob’s wasn’t regularly checked.
Question 1 has two parts:
Identify CORRECT nursing assessment performed on Mr Bright. Justify your discussion using evidence from your researched articles.
Identify those elements of nursing assessment that were NOT performed on Mr Bright. Justify your discussion using evidence from your
researched articles.
Question 2 has only one part:
Use the ISBAR format to outline your verbal handover to the doctor advising of the patient’s chest pain. Make sure it is concise and relevant to the patient’s clinical documentation.
