dignosis, intervention, outcome (goal), Rational,evaluation..
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Students are required to develop nursing care plan based on case scenario given. Identify four (4) nursing diagnoses based on Mr. Syed’s assessment. Case Scenario Mr. Syed is a 32-year-old man who admitted in the Surgical Ward at 10.00pm with complaint of abdominal pain radiated to back associate with nausea and vomiting at home. According to his wife, patient became acutely pain since early morning of the day but went to nearby clinic to get medications. But the condition of Mr. Syed unresolved and patient keep complaining of having abdominal pain followed by twice episodes of vomiting before came to hospital. Patient also complaining of unable to pass urine and feeling burning sensation when he wants to pass urine. On admission Mr. Syed vital signs was taken. His blood pressure was 135/85mmHg, respiratory rate at 28 breaths/minute; temperature was 101.7° F (38.7°C), and his SPO2 was 96% on room air, and pain score was 6/10. A STAT ultrasound abdomen was done, which shown the right lower abdominal quadrant inflamed due to perforated appendicitis. After a discussion with Doctors, Mr. Syed and his family, decided for appendicectomy operation due to a perforated appendicitis. After successful surgery, Mr. Syed transferred back to Surgical ward for further management Currently Mr. Syed is on nasal prong 3L/minutes since the patient was having difficulty in breathing due to the operation site pain 7/10. Vital signs were monitored every 2 hourly, and start IV antibiotic of Meropenem and Flagyl for tds dose. Antipyrexia tablet Paracetamol Igram has ordered QID and patient is keep NBM until further reviewed by the Surgeon. Patient receiving IV Ranitidine 50mg tds and now on 4 pint IVD regime Normal Saline for 24 hours, Patient on PCA Morphine as a pain control management. The wound dressing will be performed daily after the observation by the doctor. Mr. Syed still unable to move out from the bed and he is on continuous bladder drainage. Urine output was 100 ml/hr (yellowish color). The doctor has ordered the nurse to send the Urine for Culture and Sensitivity (C&S) to rule out any infection in the urine.
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