Start your document with the original scenario after the presentation page (VSim-suggested reading).
7. The document will include presentation and referencespage in APA style
8. Use font in “Time New Roman”, size number 12 and double space.
9. The case study must be researched and well documented with evidence-based practice.
10. Consider Maslow’s Pyramid to established priorities.
11. Apply the Nursing Process to the Case Study using Bullet Points:
a. Assessment: What will you assess in this patient?
• Select Subjective Information
• Select Objective Information
b. Analyze:
• List the top 5 nursing diagnosis for this scenario
• After prioritizing, select the most important Nursing Diagnosis
c. Planning:
• Establish a short term and a long term goal for the Nursing Diagnosis selected above. Remember, a goal should follow the SMART acronym (i.e., specific, measurable, attainable, realistic, and specify the timeframe).
d. Implementation:
• List the top 5 relevant nursing interventions for your patient according to your goals
e. Evaluation:
• List the top 5 elements you must evaluate your patient and identify the expected patient outcomes(patient findings) to that show positive progression in your patient.
• Identify the top 3 patient evaluation outcomes(patient findings) that would immediately prompt you to reevaluate your goals or implementation (nursing actions).
f. Last Page:
• Include a paragraph (more than five sentences) to describe the nursing implications for this topic.
o How important is this knowledge for nurses?
• Include a paragraph (more than five sentences) to make a personal reflection
o How does this make your feel about your role as the nurse when taking care of a patient with this diagnosis and/or past medical history?Please refer to the Reflection guidelines provided at the beginning of the course.
12. Provide more than two references in the 7th edition APA format.
Patient Introduction
Location: Medical-Surgical Unit
Time: 0800
Report from night shift charge nurse:
Situation:
Sara Lin is an 18-year-old patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.
Background:
Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.
Assessment:
Sara is alert and oriented. She needs to be reminded to use her incentive spirometer. Abdomen is soft and tender to touch. Bowel sounds active. She has progressed to regular diet, and she’s eating small amounts. No nausea reported since postoperative day 1. The surgery team changed the abdominal dressing early this morning. The incision is closed with staples; the edges are well approximated and only slightly reddened, with minimal serosanguinous drainage. Her sequential compression devices were discontinued, and the drain was pulled this morning. A small amount of bleeding was present; no further bleeding is noted. She had her first small soft brown stool since surgery this morning.
Recommendation:
You will have to transition Sara to oral antibiotics and pain medication. She last had pain medication 4 hours ago. You will need to provide discharge patient education related to incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up.
Patient Details
Patient Data: Female, Asian American, 18 years. Weight: 56 kg (124 lb), Height: 165 cm (65 in.)
DOB: 1/4/XX
Allergies: No known allergies
Immunizations: Up to date through tdap (tetanus, diphtheria, and pertussis booster) at age 15 years
Past Medical History: No previous hospitalizations or surgeries
Provider’s Orders
Admit to med-surg unit – status post open appendectomy for ruptured appendix:
Vital signs every 4 hours
Assess dressing daily and change PRN
Indwelling urinary catheter to gravity
Diet: Clear liquids, advance as tolerated
Oxygen per nasal cannula to keep SpO2 greater than or equal to 95%
Incentive spirometry every 1-2 hours
Sequential compression devices (SCDs)
Medication:
IV 5% dextrose with 0.9% sodium chloride at 125 mL/hr; decrease IV rate to 30 mL/hr when taking oral fluids
Ceftriaxone 1 g IV every 12 hours
Morphine sulphate 5 mg IV every 6 hours PRN pain
Ondansetron 4 mg IV every 8 hours PRN for nausea or vomiting
Docusate sodium 100 mg orally twice daily
Labs:
CBC and BMP daily
Call orders:
HR less than 60/min, greater than 120/min
RR less than 8/min, greater than 25/min
SpO2 less than 93%
Systolic BP less than 90 mmHg, greater than 140 mmHg
Diastolic BP less than 50 mmHg, greater than 100 mmHg
Temperature greater than 100.4 °F (38.0 °C)
_____________________________________________________________________________________
Post-op day #1 orders:
Activity: Bed rest, may get up with assistance to bathroom
Discontinue indwelling urinary catheter
Discontinue IV morphine sulfate
Discontinue IV 5% dextrose with 0.9% sodium chloride
IV to IV reservoir
Medications:
Acetaminophen 325 mg orally every 4 hours PRN mild pain level 1-3
Oxycodone/acetaminophen 5 mg/325 mg orally every 4 hour PRN moderate pain level 4-7
_____________________________________________________________________________________
Day of discharge:
Activity: Up as tolerated at home. No heavy lifting, no driving
Discontinue drain
Discontinue sequential compression devices
May shower, cover incision with dry dressing
Discontinue docusate sodium
Discontinue IV ceftriaxone
Discontinue IV ondansetron
Discontinue IV reservoir upon discharge
Medications:
Continue pain medications:
Acetaminophen 325 mg 1-2 tablets orally every 4 hours PRN for mild pain level 1-3
Oxycodone/acetaminophen 5 mg/325 mg, 1 tablet orally every 4 hours PRN for moderate pain level 4-7
Antibiotics:
Amoxicillin/clavulanic acid 875 mg/125 mg, 1 tablet orally twice daily for 7 days
Schedule follow-up in Dr. Patel’s office in one week
Discharge after 1500
