Reference no: EM133871786

Inquiry for Clinical Practice

Assessment - Case study

The learning objectives that you will evidence through this assessment are:
ULO 1: Utilise the nursing process to analyse patient information and to develop, prioritise and plan nursing care
ULO 3: Explain needs of people with regards to discharge planning

You are still caring for your patient from Assessment 2. An acute event happens to your patient which requires your detection and action to resolve, using the Nursing Process. You will be required to document a transcript of the ISOBAR handover you would give when reporting the acute event to the medical team, as well as document the event using the Data/Action/Response (DAR) method into the patient's integrated notes.

SCENARIO
Isabelle underwent her surgical # R olecranon repair yesterday morning. It is the next day, and you are on an AM shift. During handover at 0700 you are informed that Isabelle has had an uneventful post-operative period so far but is taking regular PRN oxycodone for surgical pain. Isabelle is due for her vital signs to be checked at 0800 hours. They are within normal limits, but as you are with Isabelle she tells you that she has not opened her bowels since the day before her surgery. Visually, her abdomen looks distended. She states that her stomach feels very uncomfortable. She has nil aperients charted on her medication chart. Her daily iron dose has been prescribed but she is not wanting to take it this morning, stating that she has been experiencing this problem since commencing iron three months ago. Get online assignment help in the USA!

PLEASE ANSWER QUESTIONS 1-7 and submit this document via Turnitin.
ASSESSMENT: What are the assessment findings from this scenario which alert you to there being a problem?

IDENTIFIED PROBLEM: What is Isabelle's main problem outlined above that you need to address? Please define this problem, and explain the potential adverse outcomes that may occur if the problem is not resolved. (Reference)

CARE PLAN: Outline your plan of care for Isabelle for the next 24 hours, to begin to resolve this problem. For every intervention in your care plan, please document a rationale for your action. Your rationale must be referenced.

COMMUNICATION: You call the medical team to handover Isabelle's current situation and request for her to be medically reviewed. Please document your ISOBAR handover, SPECIFIC TO HER CURRENT PROBLEM ONLY.

DOCUMENTATION: You are required to document in the integrated notes. Please document your integrated notes of what has occurred for Isabelle specifically relating to this problem, using the DAR method. Please assume that you have implemented your initial strategies but are awaiting an outcome at time of report (ATOR).

EVALUATION: What is your expected outcome for Isabelle, and how will you evaluate whether your care plan has been effective in achieving this outcome?

DISCHARGE: Isabelle is concerned about the problem she has experienced. She wants to know what she can do at home to prevent this problem happening, particularly with needing to be on iron supplements. Please provide a transcript of your education to her (Reference).