Case study ( Three Correct Nursing diagnose Action + Identify person-centered goal of care + clear rational of each nursing action + evaluate strategy determine for action

EXAMPLE of Assessment 3: Case Study Nursing Care Plan

Refer to the assessment one guidelines and rubric for further information about this assessment item.

• Although the example below does not have references your answers must be supported by evidence from at least

six different high quality sources such as peer-reviewed journal articles, textbooks, health policy, government

reports

• You are to identify your own nursing diagnoses, please do not replicate the ones below

EXAMPLE Name of patient: Mr John Smith

EXAMPLE Name of case study: Abdominal Surgery case study

EXAMPLE Day of Admission: 2

FOR EXAMPLE [Actual] Nursing Diagnosis 1:

Exacerbation of acute post-operative pain related to inadequate patient education evidenced by pain scores of 5-8.

Goal of care Nursing actions (HOW) Rationale for actions (WHY) Evaluation strategies to

determine effectiveness of

actions (How do you know

this has worked?)

The key goal of care

in relation to Mr

Smith’s nursing

diagnosis would be to

1. The first nursing action would be to

complete a thorough pain assessment

using the P Q R S T mnemonic:

A comprehensive pain assessment will

ensure that the nature and extent of Mr

Smith’s pain is fully understood. A pain

assessment will also help to determine

I would assess Mr Smith’s

pain and within one hour

following my nursing actions

I would expect Mr Smith’s

effectively manage

his pain so that his

pain score is 4 or less

and he is able to

mobilise, take deep

breaths, cough and

engage in activities of

daily living with

minimal discomfort.

P – Factors that precipitate or provoke

the person’s pain

Q – Quality and character of pain (e.g.

aching, burning, crushing etc)

R – Region (location) of pain and does it

radiate to or from other parts of the

body

S – Severity – rate intensity of pain

using appropriate pain scale

T – Time – onset and duration of pain.

The pain assessment would also include

a medical review of the analgesia

medication(s) on the patient medication

chart, checking the patient Peripheral

Venous Cannula (PVC) to ensure

patency.

the cause of the pain and whether it is

related to poorly managed post-operative

surgical pain or IV Cannula malfunction or

indicating a post-operative complication.

pain to be 4 or less and he

should be able to mobilise,

take deep breaths, cough

and engage in activities of

daily living with minimal

discomfort.

2.

3.

EXAMPLE Name of patient: Mr John Smith

EXAMPLE Name of case study: Abdominal Surgery case study

EXAMPLE Day of Admission: 2

FOR EXAMPLE [Risk] Nursing Diagnosis 1:

Risk of deep vein thrombosis (DVT) related to limited mobility and dehydration

Goal of care Nursing actions (HOW) Rationale for actions (WHY) Evaluation strategies to

determine effectiveness of

actions (How do you know

this has worked?)

It is important to

prevent DVTs rather

that manage them

after they have

occurred.

1. To prevent the likelihood of Mr Smith

getting a DVT, I would administer a

prophylactic anticoagulant as ordered

by the medical officer.

Prophylactic anticoagulant medications

such as enoxaparin sodium or heparin are

designed to inhibit the coagulation

cascade by inhibiting the conversion of

fibrinogen to fibrin and thus preventing

the formation of thrombi.

I would assess Mr Smith’s

lower limbs daily checking

for redness or discoloration,

pain or swelling as these

signs may be an early

indication of a DVT. The

preventative actions

initiated should ensure that

none of these signs are

evident.

2.

3.