Shadow Health Focused Exam Pain- Care Plan Data Patient
Edward Carter
Your Results
Overview
Care Plan : 5.5 of 7 (78.6%)
Transcript
Subjective Data Collection Nursing Diagnosis 0.5 out of
1.5
Objective Data Collection
Education & Empathy
International classification for nursing practice (ICNP) nursing diagnoses (v2019_06_27) [Data set]. (2019).
Documentation International Council of Nurses (ICN). https://www.icn.ch/what-we-do/projects/ehealth-icnptm/icnp-download
Care Plan
Diagnosis
Program Competency Progress
Video Tutorial Student Response Model Answer Explanation Points
Earned
Reflections
toileting self-care deficit chronic pain Per Mr. Carter’s self-report of 0 out of 0.5
pain on a standardized pain
scale, the chronic pain
diagnosis is correct. While Mr.
Carter is very likely to have
difficulty toileting given his
impaired mobility, a toileting
self-care deficit diagnosis
would not take priority over a
chronic pain diagnosis.
Similarly, Mr. Carter’s age and
pre-existing medical conditions
do put him at risk for impaired
skin integrity and impaired
, peripheral neurovascular
function, but the patient’s
potential to develop these
conditions is not more pressing
than the patient’s current,
quantifiable experience of pain.
Signs & Symptoms
Student Response Model Answer Explanation Points
Earned
difficulty walking difficulty walking Mr. Carter reports a recent 0.5 out of
inability to do things such as 0.5
walk and exercise. He does not
report dizziness, difficulty with
transferring or accessing the
toilet, bruising, or emotional
distress.
impaired ability to transfer pain for the past month Mr. Carter reports experiencing 0 out of 0.5
pain for "a month or so," in
addition to a pain level of 9/10
before being medicated, and a
sustained 1/10 after
medication. He does not report
dizziness, difficulty with
transferring or accessing the
toilet, bruising, or emotional
distress.
Planning 2.5 out of 3
Short-Term Goal
Student Response Model Answer Explanation Points
Earned
To have the patient, by end of To have the patient, by end of To ensure optimum patient 0.5 out of
shift, identify current pain level shift, identify current pain level compliance, ask your patient to 0.5
to achieve a comfort goal, and to achieve a comfort goal, and state back their undertsanding
report an understanding of report an understanding of of all instructions. This helps
nonpharmacological pain nonpharmacological pain you determine and address any
management methods. management methods. misunderstandings or
hesitations.
Interventions
Edward Carter
Your Results
Overview
Care Plan : 5.5 of 7 (78.6%)
Transcript
Subjective Data Collection Nursing Diagnosis 0.5 out of
1.5
Objective Data Collection
Education & Empathy
International classification for nursing practice (ICNP) nursing diagnoses (v2019_06_27) [Data set]. (2019).
Documentation International Council of Nurses (ICN). https://www.icn.ch/what-we-do/projects/ehealth-icnptm/icnp-download
Care Plan
Diagnosis
Program Competency Progress
Video Tutorial Student Response Model Answer Explanation Points
Earned
Reflections
toileting self-care deficit chronic pain Per Mr. Carter’s self-report of 0 out of 0.5
pain on a standardized pain
scale, the chronic pain
diagnosis is correct. While Mr.
Carter is very likely to have
difficulty toileting given his
impaired mobility, a toileting
self-care deficit diagnosis
would not take priority over a
chronic pain diagnosis.
Similarly, Mr. Carter’s age and
pre-existing medical conditions
do put him at risk for impaired
skin integrity and impaired
, peripheral neurovascular
function, but the patient’s
potential to develop these
conditions is not more pressing
than the patient’s current,
quantifiable experience of pain.
Signs & Symptoms
Student Response Model Answer Explanation Points
Earned
difficulty walking difficulty walking Mr. Carter reports a recent 0.5 out of
inability to do things such as 0.5
walk and exercise. He does not
report dizziness, difficulty with
transferring or accessing the
toilet, bruising, or emotional
distress.
impaired ability to transfer pain for the past month Mr. Carter reports experiencing 0 out of 0.5
pain for "a month or so," in
addition to a pain level of 9/10
before being medicated, and a
sustained 1/10 after
medication. He does not report
dizziness, difficulty with
transferring or accessing the
toilet, bruising, or emotional
distress.
Planning 2.5 out of 3
Short-Term Goal
Student Response Model Answer Explanation Points
Earned
To have the patient, by end of To have the patient, by end of To ensure optimum patient 0.5 out of
shift, identify current pain level shift, identify current pain level compliance, ask your patient to 0.5
to achieve a comfort goal, and to achieve a comfort goal, and state back their undertsanding
report an understanding of report an understanding of of all instructions. This helps
nonpharmacological pain nonpharmacological pain you determine and address any
management methods. management methods. misunderstandings or
hesitations.
Interventions
