Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Education ‫وزارة التعليم‬

University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
Student Name Sami Oqab AL Shammari
Student ID 20190372
Date 27/11/2020
Hospital General Bukeryah Hospital

Instructor Name

Patients Profile
Patient’s name (First & surname): Abd Allah Ali Al-Harby

Healthcare Record Number (HRN):

Age: 23

Gender: Male
Presenting Chief complaint: Severe Abdominal pain ( Rt Lower quadrant )
Triage category: Yellow
Infection status: Present
Accompanied by: Fever & Vomiting
Patient
Family or significant other
Source of data collection/gathering Caregiver
EMS personnel
Bystander
Use of translator
Medical Diagnosis: Acute Appendicitis

Last oral intake: 10:00 Am

1
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
Mechanism of injury (if any)
Blast Forces (Explosions)
Blunt Forces
A. motor vehicle collisions,
B. automobile versus pedestrian collisions
C. motorcycle collisions,
Types of Injuries (if any)
D. sports-related activities,
E. falls
Penetrating Forces
A. Stab wounds
B. Gunshot wounds
Mechanical energy
Type of Energy caused Thermal energy
Injury/Trauma Electrical energy
Chemical energy
Effected Organ of the
Injury/Trauma
Trauma Score (Refer to Revised
Trauma Score Appendix)

Summary of the Primary Assessment:

List all abnormalities based on primary assessment (refer to Primary Assessment Guidelines)
1\ Complaint of abdominal pain
2\ Elevated temperature
3\ Tachycardia

2
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)

History of Present Illness/injury/chief complaint

Pain
Palliative Factors Rest

Cough , walk or make any jarring movement

Provocative Factors
Sever sharp intermittent pain
Quality
Rt lower quadrant
Region
Back
Radiation
Severe
Severity
The last day ( The day before seeking medical attention )
Timing: Onset
Continues
Timing: Duration
Intermittent
Timing: Frequency
Treatment prior to Aspirin
arrival

History of Present Illness/injury/chief complaint

Fever
Palliative Factors Cold compresses

Exposure to the sun

Provocative Factors
Started as low grad fever and then became more sever
Quality
Generalized
Region
_______
Radiation
Severe
Severity
Today's morning
Timing: Onset
Continues
Timing: Duration

3
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
________
Timing: Frequency
Treatment prior to Aspirin
arrival

Pathophysiology of the Disease/ Patient condition/ Medical Diagnosis

Appendicitis is thought to result from obstruction of the appendiceal lumen, typically by lymphoid
hyperplasia but occasionally by a fecalith, foreign body, or even worms.
The obstruction leads to distention, bacterial overgrowth, ischemia, and inflammation.
If untreated , necrosis , gangrene and perforation occur.

4
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
Full Set of Vital Signs
Blood Pressure Temperature Central & Peripheral Pulse Pain
Time RR SpO2 GCS
Location Value MAP Route Value Location Rate Rhythm Quality Severity
12:00 Oral 38.4 Radial 114 Regular Strong 22 99% 15 Sever
Rt Arm 140/90 108
Pm
12:30 Oral 38.3 Radial 122 Regular Strong 24 99% 15 Sever
Rt Arm 143/96 107
Pm
1:00 Oral 38.4 Radial 118 Regular Strong 26 99% 15 Sever
Rt Arm 150/90 108
Pm
1:30 Oral 38.5 Radial 123 Regular Strong 24 100% 15 Sever
Rt Arm 147/86 107
Pm
2:00 Oral 38.4 Radial 125 Regular Strong 24 99% 15 Sever
Rt Arm 143/90 108
Pm
2:30 Oral 38.4 Radial 119 Regular Strong 22 99% 15 Sever
Rt Arm 142/96 109
Pm
3:00 Oral 38.5 Radial 123 Regular Strong 24 100% 15 Sever
Rt Arm 146/91 107
Pm
3:30 Oral 38.4 Radial 120 Regular Strong 24 100% 15 Sever
Rt Arm 144/96 108
Pm
4:00 Oral 38.3 Radial 125 Regular Strong 24 99% 15 Sever
Rt Arm 146/92 108
Pm

5
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)

Pain Assessment
Palliative Factors Rest
Cough , walk or make any jarring movement
Provocative Factors

Quality Sever sharp intermittent pain

Region Rt lower quadrant

Radiation Back
Severity* Sever (8/10)

Timing: Onset The last day ( The day before seeking medical attention )
Continues
Timing: Duration
Intermittent
Timing: Frequency
* Pain Scale used for severity assessment:
FACES pain rating scale for patients approximately 3 years of age and older
Visual analog scale for school-age children and adolescents
FLACC (Faces, Legs, Arms, Cry, Consolability) Scale for infants and preverbal children
Numeric rating scale for older school-age children and adolescents

6
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)

Diagnostic Examinations/Procedures:
(Include Blood type, Lactate, ABGS, ECG, CTCO2, Lab Tests, radiographic studies, etc…)
Reference
Value Patient
Test/Procedure Nursing Considerations
(Normal Results
Results)

Indicates a possible infection &

CBC 5,000-
14,000/µL inflammation
WBCs 10,000/µL

0.7-1.2
Serum Creatinine mg/dl
1 mg/dl Normal kidney function

INR 1-2 1 Normal INR

Prepare blood in the blood bank as

Blood Group ____ O+
ordered by the doctor

Appendice
Does not
al
Abdominal Pelvic Ultrasound exceed 6 Confirms the diagnosis of appendicitis
diameter >
mm.
6mm.

7
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)

Past Medical History

Feeling well & able to perform ADLS ( Activities of daily
Patient’s definition of own health
life ) without assistance
past medical history (PMH), to include Tonsillectomy
hospitalization/ surgeries:
Respiratory disease Infectious disease
Cardiovascular disease; Hematologic disease
risk factors Immunosuppression
Current or preexisting Neurologic disease Autoimmune disease
diseases/illness/injuries/surgeries Endocrine disease Psychological
Hepatic disease disorders psychiatric
or mental health
Others, Specify:
Medication—prescription, OTC
Food/beverages
Allergies Latex
Iodine
Environmental
Pneumococci
Immunization status Influenza
Tetanus
Childhood illnesses
Psychological/social/environmental factors
Smoking: 3-4 cigarettes aday
Substance and/or alcohol use/abuse:
Possible/actual assault, abuse, or intimate partner
violence
situations
Safety
Use of seat belts
Texting while driving
Drinking and driving
Psychiatric history (personal or family Not present
members):
Literacy (level of Education) Highly educated
Behavior appropriate for age and Normal & appropriate behavior
developmental stage:
Occupation/profession: Accountant

8
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
Meaning of illness, injury, or event to Experiencing pain & being unable to perform ADL
patient/family: ( Activities of daily living ) without needing assistance
Patient’s/family’s expectations of care: Relieving pt's pain
Family structure
Significant others
Support system: Social agencies
Religious affiliation
Caregivers
Self
Responsibilities Family
Business
Community
Cultural beliefs and practices:
Spirituality:
House
Apartment
Living accommodations
Accessibility (e.g., stairs)
Homeless, shelters
Affordability and accessibility to care— Pt has a full health insurance coverage
socioeconomic status:

History of descriptive and non-descriptive medications:
Descriptive medications (Prescribed by physician/doctor):
Generic Name & /
Trade Name Dosage Frequency Route
Classification
Cephalosporin Antibacterial Cefotaxime 2g 1×2 IV
Anti-spasmodic Spasmofree 1A 1×3 IM
Analgesic agent Diclofenac sodium 1A PRN IM
Non-descriptive medications: Legal/ illegal, over the counter drugs (OTC):
Generic Name &
Trade Name Frequency Route Rationale
/Classification

9
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
Head-to-Toe Assessment (Review of Systems)
Describe only abnormal findings: Refer to Chapter one (Nursing Assessment and Resuscitation)
General appearance

General weakness

Skin/mucous membranes/nail beds

Normal

Head and face

Normal

Eyes/ Ear/ Nose/ Mouth/ Neck

Normal

Chest

Normal

Abdomen/flanks
Reporting severe abdominal pain
Positive Psoas sign
Positive Rovsing's sign
Pelvis/perineum

Normal

Extremities

10
Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)

Normal

Posterior Surfaces

Normal

Currently Described Medications

11
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
Generic Name Trade Name/
Adverse Reactions Nursing Responsibilities
(Dosage, Route, Frequency) Classification
Cephalosporin Antibacterial Cefotaxime
 Perform an allergy test
(Cefotax) potential allergic to
before administering
2g / IV / 1×2 this medication
the medication
Anti-spasmodic Spasmofree Administer the medication on
Drowsiness,
1A / IM / 1×3 time as ordered and assess
lightheadedness and
the Pt for any adverse
dizziness
reaction
Analgesic agent Diclofenac sodium
Assess the pt's level of pain
1A / IM / PRN Increase in blood
regularly and administer
pressure
analgesics as needed
Increase in blood
Normal Saline solution 0.9% Normal Saline volume & need to Measure the fluid balance as
500 ml / IV / 1×4 Solution 0.9% monitor fluid ordered
balance

Treatments/Therapeutic Regimens/Doctor Orders rather than Medications

(e.g. oxygenation, ventilation, intubation, cardioversion, IV therapy, etc.)
IV infusion of normal saline solution 0.9% at rate of 500 ml/ 8 hrs

12
 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
NURSING CARE PLAN
(1) Acute Pain (2) Risk for Deficient fluid volume (3) Risk for Infection
Priority Nursing
Assessment Planning Nursing intervention Rationale Evaluation
Diagnosis
Subjective Data: Statement of Goal: To Pt will report 1. Put the Pt in a 1. To decrease the Evaluation of
The Pt complains of Problem (1) Acute feeling less or no pain comfortable position painful stimuli & help Goals:
severe intermittent pain Objectives: Patient will 2. Administer analgesics the Pt relax The goals were
abdominal pain in have his pain well according to doctor 2. It is preferable to partially met (The
R/T: Related to controlled
the Rt lower inflammation & orders before the pain provide an analgesic Pt reports feeling
quadrant of his obstructed appendix become more severe before the pain become less pain now
Short Term Goal
abdomen AEB: As Evidenced by 3. Provide severe when a larger 5/10)
Decrease the pain
1/ The Pt complains of intensity nonpharmacologic pain dose may be required Evaluation of
severe intermittent Long Term Goal The Pt management like 3. Such methods in pain Objectives:
abdominal pain in the will experience no pain distraction, relaxation relieve help the Pt with The Pt looks, feels
Rt lower quadrant of at all response, guided pain control his pain & and behaves
his abdomen imagery & physical reduce the dose of much more calm
Objective Data: interventions like analgesia required and relaxed and
 Positive 2/ And there are: massage, heat & cold giving better results his vital signs are
Rovsing's  Positive applications …. etc. with less side effects more stable
sign Rovsing's sign 4. Evaluate the 4. The effectiveness of
 Positive  Positive Psoas effectiveness of the treatment plan must
Psoas sign sign analgesics as ordered be evaluated
 The Pt has  The Pt has and observe for any individually by the Pt
guarding guarding signs and symptoms of since they are absorbed
behavior behavior side effects and metabolized
differently

13
 Priority Nursing
Assessment Planning Nursing intervention Rationale Evaluation
Diagnosis
Subjective Data: Statement of Goal: To Maintain fluid 1. Monitor the Pt's vital 1. To identify any Evaluation of
The Pt reports Problem (2) Risk for balance signs, capillary refill, the hemodynamic instability Goals:
feeling thirsty and Objectives: Patient will status of the mucous caused by dehydration The goals are met
deficient fluid be free from
asking about when membrane and correct it Evaluation of
volume dehydration & have Objectives:
he will be allowed
R/T: Related to adequate fluid volume  The Pt's
to drink again after 2. Discuss strategies to 2. To correct the causes
Excessive output & less fluid
the operation intake due to fever, stop vomiting & reduce of the fluid imbalance
Short Term Goal imbalance
preoperative vomiting & Correct the Pt's fluid the fever
was
postoperative imbalance corrected
restrictions Long Term Goal 3. administer IV fluids as 3.To correct the Pt's
AEB: As Evidenced by Maintain the Pt's fluid ordered by the doctor fluid imbalance  The fluid
1/ The Pt reports balance balance is
feeling thirsty 4. assess the results of 4. To identify any maintained
Objective Data: 2/ And also: the test function alteration in the serum
* The Pt's * The Pt's temperature electrolyte / kidney electrolyte levels or
temperature is high is high kidney functions which
* The Pt vomited two * The Pt vomited two may be caused by
times before coming times before coming to dehydration
to the emergency the emergency 5. Reassess the Pt's fluid 5. To monitor the Pt's
department department
balance daily as ordered fluid balance and
* The Pt is NPO * The Pt is NPO (Nothing
(Nothing by mouth)
by the doctor evaluate the Pt's
by mouth)
response to the
treatment plan

Priority Nursing
Assessment Planning Nursing intervention Rationale Evaluation
Diagnosis
Subjective Data: Statement of Goal: To (General Could be Scientific principles, Evaluation of
The Pt reports Problem (3) Risk for statement reverse the 1. Re-assessment (to theories or concepts Goals:
having fever statement of problem) look for improvement and underlying nursing Write a summary
infection Objectives: Patient will Interventions to tell why
prevent complications) statement
R/T: Related to The (specific statement each intervention
2. Independent (can be of each goal (the
risk of rupture of the define what will be should help achieve the
implemented without goal met, partially
appendix and the observed when the goal goal
doctor order) me or non-met),
surgical procedure is met which is 3. Dependent (based on Evaluation of
AEB: As Evidenced by measurable & provide Must have statement for
doctor order) Objectives:
1/ The Pt's report of time frame) each action
4. Collaborative write specific
Objective Data: having fever
(together with other statement for each
* The Pt has 2/ And also: Short Term Goal Give specific text
health care providers such objective define
increased WBCs * The Pt has increased (achievable within hours references for each
as nutritionist, physical what is observed,
count & fever which WBCs count & fever to day) intervention (name
therapist) give measurement
indicates infection which indicates a Long Term Goal of text and page and specific date
* The Pt was possible infection (achievable within days, number). and time, describe
diagnosed with * The Pt was diagnosed weeks, or month) how the patient
appendicitis which: with appendicitis Be sure to attach a looks, feels or
A. Indicates the which: bibliography. behaves after
possibility of A. Indicates the nursing
ruptured appendix possibility of ruptured interventions have
B. Necessitate the appendix been implemented.
surgical intervention B. Necessitate the
& removal of the surgical removal of the
inflamed appendix inflamed appendix
References