Identify and prioritise at least three (3) nursing problems
Case Study Instructions:
Utilise the Clinical Reasoning Cycle (Levett-Jones, 2013) (a clinical decision making framework) to plan and evaluate person-centred care:
Considering the person’s situation, collect, process and present related health information;
- Identify and prioritise at least three (3) nursing problems/issues based on the health
assessment data that you have identified for the person at the centre of care; Establish goals for priority of nursing care as related to the nursing problem/issues identified;
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- Discuss the nursing care of the person, link it to assessment data and history;
Evaluate your nursing care strategies to justify the nursing care provided;
- Reflect on the person’s outcomes.
Case Study Details – Melody King, 36, Peritonitis following ruptured:
Ms. Melody King presented to the Emergency department with 2-3 days of severe Right Lower Quadrant abdominal pain, which required emergency laparoscopic surgery for removal of a ruptured appendix. She has a past medical history of asthma and depression, with her current prescribed and compliant medications list which includes Ventolin, Seretide, Sertraline. Melody’s observations were as follows:
- BP 95/45mmHg
- HR 120
- Temp 38.3°Celcius
- RR 22/min and shallow
- SpO2 95% on room air
She complained of increasing nausea and centralised abdominal pain 7-8 on a scale of 0 to10. Physical assessment showed a distended abdomen and generalised abdominal guarding. To investigate her condition further, pathology results reveal a raised white blood cell (WBC) count and CRP. You are the RN caring for Melody post-operatively on the surgical ward.