Order 1103231: Clinical Case study post op

Process Description Darren

Describe of list facts. Context, objects

or people

This is where we begin Data Collection

Darren is a (50) year old male who is scheduled for an Open Cholecystecomy.

What else do we know about Darren -context, people and situation?

Review Current inforamtion (e.g.)

handover reports, patient history,

patient charts, results of

investigations, and nursing/medical

assessments previously undertaken.

Gather new information (e.g.

undertake patient assessment)

Admission obs And pre op assessment

Subjective & Objective: Vitals:

Respiratory Ax: CVS Ax:

Abdo Ax: Pathology:

Recall knowledge (e.g.

pathophysiology, phsyiology,

pharmacology, epidemiology,

therapuetics, culture, contexct of

care, ethics, law)

Consider pathophysiology of upcoming surgery -what is a cholecystectomy? What is

the difference between a Laproscopic procedure and an Open procudere? How will

this impact Darrens recovery? Why? Consider Darrens history -

what impact will this have on his anaesthetic risk/recovery/post-operative

complications? What are the issues around Legal -consent etc

Interpret: analyse data to come to an

understanding of signs or symptoms.

Compare normal vs abnormal

Discriminate: distinguish relevant

from irrelevant information;

recognise inconsistencies, narrow

down the information to what is most

important and recognise gaps in ccues

collected.

This is where we begin to Cluster the data, to make sense of it in this patient context.

Relate: discover new relationships or

patterns; cluster cues together to

identify relationships between them.

Infer: make dedcutions or form

opinions that follow logically by

interpreting subjective and objective

cues; sconsider alternatives and

consequences.

Match: current situation to past

situations or current patient to past

patients [usually an expert thought

process]

Predict: an outcome [usually an

expert thought process]

Synthesis: facts and inferences to

make a definitive diagnosis of the

patients problem.

Nursing Daignosis - Can be Auctal or Potential.

The Problem realted to the Aetiology (cause) as evidenced by the signs & symptoms.

Describe what you want to happen, a

desired outcome and a time frame

Goal for solving the patients problem. Can be short term or long term -

Needs to be SMART

Select a course of action between the

different alternatives available

These are your Nursing Interventions -how you are going to achieve the Goal and Solve

the problem.

Evaluate the effectiveness of

ourcomes and actions. Ask: Has the

situation improved now?

How has the situation improved and How do we know it has improved. i.e. -

Evaluations need to be measureable (Vital signs, Pain Score etc.)

Contemplate what you have learnt

from this process and what you cuold

have done differently.

Reflection