HPI: 42 young female was evaluated for psychiatric evaluation and
Patient Information: Name: Nisha Khan Date of Birth: 16 March 1952 Address: 79 Brussel Street, Caloundra Mobile: 0412 157 889 Background: Nisha identifies as a female originally from Jaipur, India, but has lived in Queensland with her daughter for 10 years. She expresses concern about the slow healing of her leg. Patient Presentation: Nisha arrives at the treatment room, holding her daughter’s arm. She is here for a review and a change of dressing following a fall seven days ago while shopping, which injured her left shin. Nisha has limited proficiency in English, so her daughter helps with translation. Medical History: Type 2 Diabetes Renal stones (both conditions are controlled) On the waiting list for bilateral cataract surgery Her daughter mentions that the cataracts are impairing Nisha’s vision and affecting her independence, necessitating assistance with showering and mobilising in low-light conditions. Vital Signs: Temperature: 37.5°C Pulse: 88 bpm Respiratory Rate: 18 breaths per minute Blood Pressure: 128/88 mmHg Pain Score: 3/10 Blood Sugar Level: 5.8 mmol/L Wound Assessment: Upon removing the dressing, it is noted to be wet. The daughter said that it had soaked during the shower this morning. The wound measures 3 cm x 1 cm and has a depth of 3 mm. It appears light pink with a slight yellow/green exudate. There is no slough present. Redness is observed around the wound’s edges, and the surrounding skin feels warm to the touch. A faint odour is detected when the dressing is removed NUR114 Task 2b Describe how you will meet each of the AIDET stages in brief when first meeting the case study person. A I D E T Demonstrate your knowledge of care planning (ADPIE) Assessing (Collecting the data) Identify subjective and objective data from the case study to identify problems/issues that require addressing. (responses 3-5) Thinking space: Moving from assessing (data collection) to making an assessment (Nursing diagnosis). (This does not count in the word count) List some key problems you can see from the above data. Create two nursing diagnoses (actual or potential problems) Problem Aitiology/Cause 1. 2. Applying each nursing diagnosis, you have identified above, develop a person-centred plan/goal and implementation of your care for the case study provided. (approx. 100 words) Nursing Diagnosis Plan/Goal Implementation Consider how you might evaluate these patient goals. Include supporting references. Select one of the Standards of Practice for the Registered Nurse and reflect on how this is applied to your learning in this assessment task. Addressing legal requirements for completing nursing documentation (as required for IEMR). Demonstrate documentation of nursing notes for the case study using the systems approach. Patient Identification Surname: ……………………………………………………. UR: ……………………………. Other Names: ……………………………………………… Address: Ph No: Date of Birth: ……………………………… Sex: ê™± M ê™±F ê™±Other Log on: Log off: Document the vital signs on the ADDS form. In the Task 2 assessment folder print a hard copy of the QADDS form. Manually document complete the documentation for the case study and vital signs. Using your phone, take an image and upload this to this file. References
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