Karen Cole Scenario 1

Karen Cole

Scenario 1

Patient arrives at the unit with her husband. You have introduced yourself to the patient, and she is now in bed."

Initial Assessment

 Introduction and Rapport Building

 Thank you for coming and welcome to the facility Karen and her husband.

 You should take your time and Introduce yourself, your position and what you are about to do.

 Patient Identification and Safety

 Make sure you check her details that is her full name and her date of birth from the ID band.

 Therefore, the patient’s medical record should be checked to have a grasp of how the patient was and is at present.

 Key Questions to Ask

 The Present Status and the Presenting Complaint

 Ask Karen: “How do you feel at the moment, are there any problems that you are having at the moment?”

 Inquire about any pain or discomfort: “Are you currently experiencing any pain or discomfort? If so, please could you describe it?”

 Previous Health and Recent Trends in Health Status of the Population

 “Have you observed any alterations in your health or the appearance of any new signs or symptoms?”

 Look at her past illnesses and surgeries, and past hospitalizations.

 Medication and Treatment History

 “At the moment what medications are you on, this may include the prescription medication, over the counter medication and supplements?”

 Is there any change in medication in the last few weeks or she is already taking some new medication.

 Support and Preferences

 Ask Karen and her husband about any preferences for care: “Are there any specific thing you like or do not like while you are here?”

 Request her whether she has any form of an advance directive or specific instruction to be made.

 Family and Social Support

 “With whom can one discuss the concerns regarding the patient’s care or the people who should be included in the decision making? “

 Documentation and Communication

 Document Findings

 Any information that the patient is going through, feelings, and/or symptoms that the patient may be having, as well as, preferences and medical records.

 It should also be ensured that all and sundry is properly documented in Karen’s file.

 Team Communication

 The other team members should be informed on the issue with Karen and any advice that she provided or issues that she has.

 Explain to the healthcare team that she needs a good care plan to be made as she is a unique individual.

 Follow-Up Actions

 Plan for Care

 Revise or create the care plan whilst using the information that has been obtained:

 Ensure that all aspects in relation to Karen’s care are provided for; this is her pain, medication and any investigations that might be required.

 Patient Education

 Ensure that the family of the patient especially Karen and her husband is informed of the care plan, the procedure to be done, or any changes that will be made on the treatment plan.

 Ensure that they know how to approach the healthcare providers if they have some questions or problems regarding their health.