Question

Case Scenario- Nesha Patel

Location: Surgical Unit 0800

Report from night shift charge nurse:

Situation: Nesha Patel is a 48-year-old female Indian patient who had an emergency appendectomy. Nesha does not speak any English. It is day 1 postoperative, and Nesha is expected to be discharged late tomorrow afternoon. We have her IV antibiotics and will discontinue after her morning dose. She will be getting oral meds today. What pain scale should be implemented? How will you communicate with Nesha?

Background: Nesha 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 complaining of pain since arriving to the unit. Her family has not been in contact with Nesha. From her chart, Nesha had a left breast biopsy one month ago and waiting on biopsy results.

Assessment: Nesha is appears alert and oriented, appropriate for age. She needs to be reminded to use her incentive spirometer. Abdomen is soft, tender to touch. Bowel sounds active. She has progressed to liquid diet, and she's having small amounts. No nausea reported since postoperative day. The abdominal dressing was changed by the surgery team early this a.m. The incision is closed with staples; the edges are well-approximate and only slightly reddened with minimal serosanguinous drainage. Her sequential compression devices were discontinued, and her Jackson-Pratt drain will be pulled this evening. A small amount of bleeding is present; no further bleeding is noted. This morning, she had her first small soft brown stool since surgery.

Recommendation: You will have to transition Nesha to oral antibiotics and pain medication. She last had IV pain medication 4 hours ago. You will need to provide discharge patient education on incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up.

Medications:

Norco (acetaminophen hydrocodone)   2.5 mg to 5 mg   po Q 4-6 Hours

Vancomycin 500mg   po     Q 8 Hours

Tylenol 500mg   po   2 capsules    Q 4-6 Hours

NURSING CARE PLAN- Utilize your assessment data and the NURSING PROCESS to create an individualized Care Plan for your patient, be specific to their needs.

Nursing Diagnoses Use your Assessment data to ID clinical problems	Expected Outcomes (S.M.A.R.T.) Specific, measurable, attainable, realistic, & time-oriented (ID a future time or date for reassessment/evaluation)	Nursing Interventions What can you, the nurse, do to reach the goal and improve the problem?
#1 R.T. A.E.B.	The patient will… Short-term goal: Long-term goal:	The nurse will… 1. 2. 3. 4.
#2 R.T. A.E.B.	The patient will… Short-term goal: Long-term goal:	The nurse will… 1. 2. 3.

I need 2 nursing diagnosis and 2 care plans in 30 minutes please.

Answer 1