Case Scenario #8

Ambulatory Patient Care Scenario

Instructions: For this case scenario you will develop a nursing care plan using the Standardized Nursing
Languages (SNL) of NANDA, NOC & NIC. You will be completing the blank telephone encounter form
that accompanies scenario.

• Mrs. Carter is a 56 y.o. female, who was seen five days ago in your surgical clinic by Dr. Such&so.
Mrs. Carter was discharged from the hospital eleven days ago following surgical removal of a benign
abdominal cyst.

• The patient has telephoned the clinic complaining of post-operative problems, specifically with her
abdominal incision. In the last twenty-four to thirty-six hours, Mrs. Carter has noticed her incision
is mildly though continuously tender to touch, & appears slightly reddened & swollen. She denies any
drainage. Mrs. Carter does note that she’s feeling ”run down” & “washed out,” more so than any time
since her operation; she had anticipated being recovered from her surgery by now, & fully returned
to her prior activity level. She periodically feels “warm” & flushed, but hasn’t checked her
temperature because she’s unsure how.

• Mrs. Carter denies any nausea or vomiting, diarrhea or constipation since her post-operative visit.
Her past medical history is non-contributory; she has no known (medicinal) allergies. Currently, Mrs.
Carter’s medications consist of Tylenol on an as-needed basis. She has taken Tylenol four times in
the last twenty-four hours, for incisional tenderness.

• Mrs. Carter notes that she was instructed, at her post-operative visit, that dressing the incision was
no longer necessary. She also states she was instructed that she could now resume her usual hygiene
practices, & has taken a tub bath twice since her last clinic visit.

Functional Health Patterns

Nursing assessment data is organized in Functional Health Patterns. Functional Health Patterns can help
direct the choice of Nursing Diagnoses. The eleven functional health patterns are:

Health Perception–Health Management Cognitive–Perceptual

Nutritional-metabolic Elimination
Activity-Exercise Sleep/Rest
Self-Perception/Self-Concept Role/Relationship
Coping/Stress/Tolerance Sexuality/Reproductive
Value/Belief

The Functional Health Patterns that are relevant for Mrs. Carter, listed in order of importance, are:

Health Perception–Health Management

Cognitive–Perceptual
Activity-Exercise

Relevant information should be recorded in Assessment, Past Medical History & Current
Medications on the Patient Telephone Encounter form.
Step 1. Choosing the Nursing Diagnosis (es) (NANDA)

The following nursing diagnoses are appropriate for this patient. In practice, you may select additional
nursing diagnoses.

Nursing Diagnosis: Infection, Risk for

Defining Characteristics: Patient complains of incision is tender to touch, & appears
reddened & swollen. She denies any drainage.
Risk Factors: Invasive procedure
Nursing Diagnosis: Knowledge Deficit
Defining Characteristics: Patient says she hasn’t checked her temperature because she’s
unsure how.

Nursing Diagnosis: Fatigue

Defining Characteristics: Mrs. Carter does note that she’s feeling a ”run down” & “washed
out;” she had anticipated being fully returned to her prior activity level.

While each of these nursing diagnoses are appropriate, for the purposes of this exercise let’s use the
second diagnosis, Knowledge Deficit

On the Patient Telephone Encounter form, check the nursing diagnosis, correlating them with the
assessment data you have gathered. In the event that diagnosis selections are not listed as choices
among Chief Nursing Diagnosis, you will need to write them in as “other.”

Dr. Such&so is consulted as a result of Mrs. Carter’s contact with the clinic. He orders blood
cultures to be drawn & oral antibiotics, Cephalexin 750mg PO Q6 hrs x 10 days, after obtaining
these cultures.

Step 2. Choosing the Nursing Outcomes (NOCs).

The next step is to select nursing outcomes, either among the nine listed or adding others, that can best
affect the nursing diagnosis. Listed below are two appropriate nursing
outcomes, for the NANDA, Knowledge Deficit

Nursing Outcomes: Knowledge: Medication

Indicators: recognition of need to inform health provider of all medications being taken
statement of correct medication name
description of side effects of medication
description of medication precautions
description of correct administration of medication

Each pertinent indicator should be closely monitored, both upon initial contact & thereafter until
diagnosis resolution.
Nursing Outcomes: Knowledge: Infection Control
Indicators: description of practices that reduce transmission
description of monitoring procedures
description of follow-up for diagnosed infection

Select one of the above listed nursing outcomes for this care plan exercise. Rate Mrs. Clark’s current
status by using a circle (â) to indicate the score that best represents her status. Use a triangle (ã) to
select the score that will best represent the desirable score for Mrs. Clark.

Step 3. Choosing the Nursing Interventions. (NICs)

Having selected an outcome for Mrs. Clark, you will need to select the interventions that will best move
her toward this outcome. The following Nursing Interventions are appropriate for this patient. Review
the activities listed below each NIC & select five.

NIC: Other - Infection Control

Activities – ensure appropriate wound care technique
encourage fluid intake (as appropriate)
encourage rest
instruct patient to take antibiotics, as prescribed.
These are the discrete activities selected to comprise our individualized Infection Control intervention;
these represent only a portion of the available activities (see NIC, 3rd edition, page 398).

NIC: Medication Management

Activities - For the purposes of this scenario, assume you’ll instruct Mrs. Clark on how to: monitor
patient for therapeutic effect of medication
facilitate changes in medication with physician, as appropriate
teach pt and/or family the expected action and side effects of the
medication
obtain physician order for patient self-medication, as appropriate
instruct patient when to seek medical attention
Again, these are discrete activities selected to comprise our individualized Medication Management
intervention; these represent only a portion of the available activities (see NIC, 3rd edition, page 451).

The remainder of the Patient Telephone Encounter form (Comments/Provider orders & Disposition of
Care) documents the implementation of these Nursing Interventions, & plans for necessary monitoring.
Included among these plans is a scheduled follow-up, by the nurse, with the patient; we are to call Mrs.
Clark back, & check on her status, in twenty-four hours.
Instructions: For this case study, you will evaluate your patient’s progress against
the nursing care plan, you have just developed. You will document this progress
utilizing the Follow-Up Patient Telephone Encounter form.

Twenty four hours after Mrs. Clark’s call to the clinic, you have made arrangements to contact her in
order to follow-up with medical & nursing interventions, & to determine progress toward identified
outcomes.

Mrs. Clark reports that her initial temperature yesterday was 100.2 F; now twenty hours later, Mrs.
Clark’s temperature is 99.2. Additionally, she reports a good nights sleep last night, & feels quite rested
this afternoon, more her usual old self. She notes her incision seems top feel less sore, & thinks the
Tylenol might be working better than it did before. Her incision continues to evidence no drainage, & is
less red than it was yesterday.

She took the initial dose of her antibiotic prescription at 2 PM yesterday, & three doses since.

Record the pertinent information as assessment information. Reevaluate nursing outcomes; whether or
not differences exist between values identified yesterday & those of today. Ascertain if interventions
selected yesterday remain appropriate; are additional interventions needed?

Based upon your nursing (re) assessment, & perhaps follow-up consultation with the physician (as
necessary), determine what events will complete Disposition of Care.
 UNIVERSITY OF MICHIGAN HEALTH SYSTEM
Date Time
Birthdate Provider
REASON FOR CALL:
Sick
Treatment/Medication Question
Prescription Refill
Pharmacy Name ______________
Pharmacy Phone______________
MEDICATION
Medication Refill
Request
Message taken by _______________________________
ASSESSMENT (CHIEF COMPLAINT/ SYMPTOMS/DURATION/SIGNIFICANT FINDINGS):
ALLERGIES:
PAST MEDICAL HISTORY:
CURRENT MEDICATIONS/TREATMENTS/THERAPIES:
CHIEF NURSING DIAGNOSIS: (CHECK APPROPRIATE DIAGNOSIS)
Activity intolerance
Activity intolerance, risk for
Adjustments, impaired
Airway clearance, ineffective
Altered body temperature, risk
for
Anxiety
Aspiration, risk for
Body image disturbance
Bowel incontinence
Breathing pattern, ineffective
Cardiac output, decreased
Caregiver role strain
Caregiver role strain, risk for
Constipation
Constipation, Risk of
Okay to file
PATIENT TELEPHONE ENCOUNTER
Insurance
Referral _________________
Test Results _____________
__________________________
Can Results Be Left On
Answering Machine
# Left
Date/Time ______/_______
Diarrhea
Disuse, risk for
Diversional activity deficit
Family coping, ineffective
Family coping – potential for
growth
Family process, altered
Fatigue
Fear
Fluid volume deficit
Fluid volume deficit, risk for
Fluid volume excess
Fluid volume imbalance, risk for
Gas exchange, impaired
Health seeking behavior
Hyperthermia
Individual coping, ineffective
Patient Name
Registration #
CALLER: Patient Spouse MD
Pharmacy Home Care Group Home
Parent Other:_________________
Y/N Home Phone:_________________________
Alternate Phone:_______________________
Strength Frequency Quantity Given Refills Given
Voice Mail: Y N Date/Time Retrieved: ______/______
Infection, risk for Self esteem disturbance
Injury, risk for Situational low self esteem
Knowledge deficit Skin integrity, impaired
Management of therapeutic Skin integrity, risk for impaired
regimen, effective
Management of therapeutic Sleep deprivation
regimen, ineffective
Management of therapeutic Sleep pattern disturbance
regimen, ineffective - family
Nausea Spiritual distress
Noncompliance Spiritual distress, risk for
Nutrition, altered – less than Tissue integrity, impaired
body requirements
Nutrition, altered – more than Tissue perfusion, altered
body requirements
Oral mucus membrane, altered Urinary elimination, altered
Pain Verbal communication, impaired
Pain, chronic Walking, impaired
Peripheral neurovascular Other (specify)____________
dysfunction, risk for
Physical mobility, impaired Other (specify)____________
Potential for enhanced spiritual Other (specify)____________
well-being
 UNIVERSITY OF MICHIGAN HEALTH SYSTEM

PATIENT TELEPHONE ENCOUNTER

Nursing Outcomes Nursing Interventions
Current Active Listening
Status
Emotional Support
Worst
State

State
Best
Desired
Status Counseling
Pain Level 1 2 3 4 5 Crisis Intervention
Coping 1 2 3 4 5 Self Care Assistance
Knowledge 1 2 3 4 5 Medication Management
Quality of Life 1 2 3 4 5 Nutrition Management
Self Care 1 2 3 4 5 Teaching/Education
Mobility 1 2 3 4 5 Health System Guidance
Compliance 1 2 3 4 5 Pain Management
Risk Control 1 2 3 4 5 Family Support
Anxiety 1 2 3 4 5 Other_________________________________________________
Other________ 1 2 3 4 5 Other_________________________________________________

__________________________________Protocol Utilized
Comments/Provider orders:

DISPOSITION OF CARE:
Prescription Authorized Prescription called in/ mailed by:_______________________________________
Signature/Title Date/Time
Referral Authorized for ________________________________________________________________________
Emergency Room or L&D Advised Declined Authorization for: _____________________________
Appointment Advised Appt. Made________________ Appt. Not Necessary at this time Declined
Consultation and /or follow-up with:____________________________________________________________________
Instruction/Information Verbalized Understanding
provided___________________________________________

Advice per________________________________________________ Protocol Home Care

Results provided Report called to: ________________________________________

Call back on _________________ (date) to assess outcomes.

Signature Title Date Time

Signature Title Date Time

Signature Title Date Time

Telephone Consultation (Initial) <5 minutes <10 min 11-20 min 21-30 min 31-40 min 41-50 min 51-60 min >60 min.
Telephone Consultation (Total) <5 minutes <10 min 11-20 min 21-30 min 31-40 min 41-50 min 51-60 min >60 min.

6
 UNIVERSITY OF MICHIGAN HEALTH SYSTEM

PATIENT TELEPHONE ENCOUNTER

Follow Up
Patient Name

Date Time Registration #

ASSESSMENT:

Nursing Outcomes

Not Compromised
Compromised

Compromised

Compromised

Compromised
Substantially

Moderately
Extremely
Circle number to indicate present status

Mildly
Consistently
Sometimes
Rarely
Never

Often

Anxiety Elimination
• Controls anxiety response 1 2 3 4 5 • Elimination pattern in expected range 1 2 3 4 5
• Reports adequate sleep 1 2 3 4 5 • Urine/stool passage without pain 1 2 3 4 5
• Other: 1 2 3 4 5 • Other: 1 2 3 4 5
Compliance Nutritional Status
• Reports following prescribed regimen 1 2 3 4 5 • Food and fluid 1 2 3 4 5
• Other: 1 2 3 4 5 • Weight 1 2 3 4 5
Coping • Other: 1 2 3 4 5
• Uses available social support 1 2 3 4 5 Wound healing
• Uses effective coping strategies 1 2 3 4 5 • Resolution of edema 1 2 3 4 5
• Other: 1 2 3 4 5 • Resolution of wound odor 1 2 3 4 5
Risk Control • Other: 1 2 3 4 5
• Modifies lifestyle to reduce risk 1 2 3 4 5
• Uses health care services to control risk 1 2 3 4 5

Substantial

Moderate
• Other: 1 2 3 4 5
Severe

Slight

None
Pain
• Reported pain 1 2 3 4 5
• Frequency of pain 1 2 3 4 5
Substantial

Knowledge (Specify • Length of pain 1 2 3 4 5

Extensive
Moderate
Limited
None

Indicators)
• 1 2 3 4 5 • Other: 1 2 3 4 5
• 1 2 3 4 5
Dependent does

assistive device
Requires Asst.
not participate

• 1 2 3 4 5
per. & device

Independent

independent
Completely
with assis.
Requires

Device

Self Care
Substantially

Moderately
Extremely

Mildly

Quality of Life • Eating 1 2 3 4 5

Not

• Satisfaction with health status 1 2 3 4 5 • Hygiene 1 2 3 4 5

• Satisfaction with achievement of life goal 1 2 3 4 5 • Other: 1 2 3 4 5
Mobility
• Satisfaction with close relationships 1 2 3 4 5 • Muscle movement 1 2 3 4 5
• Other 1 2 3 4 5 • Ambulation (walking) 1 2 3 4 5
• 1 2 3 4 5 • Other 1 2 3 4 5
NURSING INTERVENTIONS:
Active Listening Self Care Assistance Health System Guidance
Emotional Support Medication Management Pain Management
Counseling Nutrition Management Family Support
Crisis Intervention Teaching/Education Other ___________________________
Okay to file

7
 UNIVERSITY OF MICHIGAN HEALTH SYSTEM

PATIENT TELEPHONE ENCOUNTER

Follow-Up
Comments/Provider Orders:

DISPOSITION OF CARE:
Prescription Authorized Prescription called in/ mailed by:_______________________________________
Signature/Title Date/Time
Referral Authorized for ________________________________________________________________________
Emergency Room or L&D Advised Declined Authorization for: _____________________________
Appointment Advised Appt. Made________________ Appt. Not Necessary at this time Declined
Consultation and /or follow-up with:____________________________________________________________________
Instruction/Information Verbalized Understanding
provided___________________________________________

Advice per________________________________________________ Protocol Home Care

Results provided Report called to: ________________________________________

Call back on _________________ (date) to assess outcomes.

signature Title Date Time

signature Title Date Time

signature Title Date Time

Telephone Consultation (Initial) <5 minutes <10 min 11-20 min 21-30 min 31-40 min 41-50 min 51-60 min >60 min.
Telephone Consultation (Total) <5 minutes <10 min 11-20 min 21-30 min 31-40 min 41-50 min 51-60 min >60 min.