Module 2

Planning patient care

This module is the second of four modules which deal with aspects of the
four steps in the nursing process; assessment, planning; implementation,
and evaluation. This module focuses on key skills that international nurses
need to help them plan care for their patients and write effective care plans.

Nursing – Module 2 Planning patient care

Theme Page titles Page reference ESOL

Writing care plans Focus 2.1

How to write a goal statement 2.2, 2.3 Rw/L1.2a; Wt/L1.4a
How to get the style right 2.4 Wt/L1.4a; Wt/L2.5a; Rw/L1.1a
How to write precise goals 2.5 Wt/L2.2a; Wt/L2.5a;
Rw/L1.1a; Wt/L1.6a; Wt/L1.7a
How to write nursing actions 2.6, 2.7 Wt/L2.6a; Wt/L1.7a; Wt/L1.4a

Discussing care Focus 2.12

How to follow feedback 2.13 Lr/L1.1b
How to respond to feedback 2.14 Lr/L2.2d
How to respond to suggestions 2.15 Sd/L1.2b
How to make sure you understand 2.16 Lr/L1.3a
feedback
How to be proactive in discussions 2.17 Sd/L1.2b; Lr/L1.3a; Sd/L1.2c
about care

Dealing with a Focus 2.20

deterioration in a patient’s
condition
How to ask for assistance
How to reassure and calm a patient
How to sound reassuring
How to keep a patient calm and
reassured
2.21, 2.22 Lr/L1.2b; Lr/L2.2d; Sc/L1.3a
2.23, 2.24 Lr/L1.2d; Lr/L1.6c; Sd/L2.5a
2.25 Lr/L1.2b; Lr/L2.5a; Sc/L2.1a
2.26 Lr/L1.2b; Sd/L2.2d; Sd/L2.5a

129
 Nu Module 2 Planning patient care

Skills checklist
These are some of the skills you will need when admitting
patients in your workplace.

Tick the skills you feel confident with now and the ones you
need to practise.

Skills for planning care for patients I feel I need more Pages
confident practice
Theme 1 Writing care plans
Know what information to include in a ➪ 2.1, 2.6
care plan
Write clear goals statements for a care plan ➪ 2.2, 2.3,
2.4, 2.5
Write clear nursing actions for a care plan ➪ 2.6, 2.7
Theme 2 Discussing care
Follow feedback on care you’re planning ➪ 2.13
Respond to your supervisor’s feedback ➪ 2.14, 2.15,
and suggestions 2.17
Clarify and check to make sure you ➪ 2.16
understand feedback
Theme 3 Dealing with a deterioration
in a patient’s condition
Ask for assistance and give a clear update ➪ 2.21, 2.22
on changes in the patient’s condition
Reassure and calm a distressed patient ➪ 2.23, 2.24,
2.25
Use your voice to sound reassuring and calm ➪ 2.25

Don’t forget! When you have worked with the material, look at the checklist again.

130
 Nu Module 2 Planning patient care
PAGE 2:1
Writing care plans
Professional setting
The topic of the theme is developing care plans,
and deals with the following:
■ identifying problems and deciding on the
nursing goals for the patient
■ identifying appropriate nursing actions
(interventions) for meeting those goals. This
includes actions the nurse does for and to the
patient (e.g. monitoring blood pressure) and
actions to assist or supervise the patient (e.g.
assisting the patient with dressing or
supervising them when showering)
■ documenting care so that other members of the
care team can read it easily.
The focus is on skills for writing clearly and
precisely and draws on examples of individualised
and standard care plans. The theme also seeks to
raise awareness of the importance of documenting
and signing care forms as a legal requirement.
Materials
Blank cards/sticky notes for writing up new words
Photocopies of Resources for the theme
Sample care plans from the Source material
Sample care plans used in the learners’ workplace
Dictionaries and medical glossaries
OHP and transparencies (optional)
Learning outcomes/objectives
1 to recognise features of goal statements for
planning nursing care
2 to write goal statements using appropriate
content and grammatical structures
3 to be aware of appropriate style when writing
goals e.g. choice of register and vocabulary
4 to practise writing clear and precise goal
statements
5 to recognise features of statements of nursing
actions, their structure, content and style
6 to write clear and precise statements of nursing
actions using appropriate style and vocabulary
131
Curriculum objectives
ESOL
Rw/L1.2a; Wt/L1.4a; Rw/L2.1a; Wt/L2.2a;
Wt/L2.5a; Rw/L1.1a; Wt/L1.6a; Wt/L1.7a;
Wt/L1.4a
Focus
Suggested teaching activities
■ Set the context by asking learners about their
experience of planning in their daily lives, e.g.
picking up children from school, organising an
event for family and friends, changing jobs,
etc. and why some plans are successful and
others are not, e.g. lack of communication or
commitment, unexpected changes, over-
ambitious time scale, not being specific enough
about who has to do what, etc.
■ Discuss learners’ experience of care planning in
their countries / other countries where they
have nursed and how this differs in the UK.
■ Ask about forms that are used in hospitals
where they work and refer learners to examples
of individualised plans and standard care plans
in the Source material. Discuss the kind of
information care plans typically contain and
elicit a definition of a goal, i.e. a desirable
future state towards which the nurse and
patient are working.
■ Discuss criteria for goals, eliciting what learners
understand by these terms in the context of
care planning:
– achievable
– realistic
– clear and precise
– measurable.
■ Point out that the way in which a plan of care
is recorded varies from setting to setting and
the importance of becoming familiar with
forms and policies for recording care in
different workplaces.
 Nu Module 2 Planning patient care
■ Set up these two preliminary discussion points
for groups, with each group briefly reporting
back.
Discussion point 1
What are the benefits and drawbacks of using
standard/core care plans? (See examples in the
Source materials), e.g. reduces amount of paper
work, releases time for more valuable nursing
activities, lack of individualisation of care.
Discussion point 2
What are the benefits and drawbacks of
computerised forms? (e.g. greater accuracy,
improved communication, more effective
retrieval of information, time-saving, faster
analysis of information, easier to read, easier to
track changes, easier access by care team if
computers are networked).
Task 1
■ Set up the task. Allow time for learners to read
the extract from the care plan. Ask general
questions about the plan, e.g. the nature of the
patient’s problem, the medication he’s taking,
how serious his condition is.
■ Learners then try the task and discuss answers
in pairs/groups, providing evidence from the
plan to support their choices, e.g. the omission
of words like a/an, the, and pronouns in the
notes.
■ Go through each of the points in the care plan.
Focus on the importance of signing and dating
the plan, and the associated legal implications.
As follow-up, encourage learners to go to the
publication section of the NMC website to read
the guidelines on record-keeping.
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PAGE 2:2
How to write a
goal statement 1
Task 2
Introduction and curriculum references
to be aware of what information needs to be
included in a goal statement
to be able to choose the right structure for a goal
statement
ESOL
Rw/L1.2a
Notes
■ The task focuses on the content that needs to
be included in a goal statement. Depending on
the background of the international nurses in
the group, this may be a new concept.
■ Go through the points in the information
section of the page, eliciting other examples for
each section. Learners can try the task in pairs
or individually.
■ As follow-up, elicit examples from the learners’
own experience of planning care for patients
and the goals for their nursing care. Working in
pairs, learners can then discuss specific goals
for a patient, organising the information in a
similar table.
If the learner has difficulty
Work through the examples with learners step-by-
step, completing the table. Then ask them to
discuss in pairs specific goals for a patient they
have nursed, completing notes for each part of
the table. In that way they will know they have
all components for the goal.
Extension
Encourage learners to look at care plans in their
workplace and assess whether they contain all the
components.
 Nu Module 2 Planning patient care

PAGE 2:3 Examples:

■ For Mr Khan / to explain / the role of insulin /
How to write a ■
in carbohydrate metabolism / by 13 April.
Mr Khan / will administer / his own insulin /

goal statement 2 based on morning blood sugar / by 20/4.

Extension
Task 3 Encourage learners to write goal statements for
Introduction and curriculum references patients in their care or patients they have cared
for previously.
to be able to write clear goal statements using
appropriate sentence structure
to develop understanding of the need to be
explicit when writing goal statements

ESOL
Wt/L1.4a

Notes
■ Set the context: an older female patient
admitted after a stroke.
■ The point of the task is to focus on two useful
sentence patterns for writing objectives, future
with ‘will’ (Mrs … will communicate) and the
infinitive, to + verb (For Mrs Zanni to feed ...).
■ Elicit other examples from learners for other
patients, e.g. a patient who has had a hip
replacement; an older patient with anorexia.
Put some examples on the board / an OHT.
■ For question 2, learners expand the notes to
form statements using the future with ‘will’ or
the infinitive to + verb, including all the
required elements. Take feedback.

If the learner has difficulty

■ Work with learners to complete the first
example in question 2.
■ Learners then work in pairs to think about
specific goals for patients, and develop similar
statements.
■ Give practice in rephrasing some goals, e.g.
– Rephrase using future with ‘will’: For Mrs
Adams to walk to the dining room for all meals,
using her stick with the support of one nurse.
– Rephrase using the infinitive (to + verb): Mr
Clark will shower three times a week, supervised
by a nurse.
■ Alternatively, write some goals on cards and cut
them up for learners to re-order. This will help
learners focus on the sentence patterns and
order of information.

133
 Nu Module 2 Planning patient care

PAGE 2:4 If the learner has difficulty

■ For question 1, put the words on cards so that
How to get the learners can physically move them around as
they match them.

style right ■ For question 2, give learners the verbs they will
need to complete the sentences.
■ For more practice with time prepositions and
Task 4
phrases and expressions for frequency, use the
Introduction and learning objectives answers for 4.2 or 5.1, blanking them out so
to use appropriate formal register and vocabulary that learners can complete them. Alternatively,
when writing goals encourage learners to review prepositions by
directing them to a section on prepositions in a
to choose formal language appropriate to writing
good grammar book.
goals
to recognise and understand vocabulary Extension
associated with a care plan ■ Try the extension task in the Resources for the
theme. The aim is to increase the range of
ESOL
measurable verbs learners know for stating
Wt/L1.4a; Wt/L2.5a; Rw/L2.1a goals in care plans.
■ Encourage learners to find other examples to
Notes
add from care plans in the theme, the Source
■ The focus of the tasks on this page is to raise material and from care plans from work.
awareness of the more formal vocabulary and
style that is appropriate for writing goals.
■ For question 1, learners can work in pairs to
discuss the words and match them. They may
need to check some verbs in a dictionary or
medical glossary. Point out that for some of the
everyday verbs there is more than one more
formal equivalent.
■ For question 2, learners use some of the verbs
to complete the goal statements. Take feedback.
■ Follow up by focusing on prepositions and
other time phrases that are widely used in care
plans, e.g. by + date (the last possible time for
doing the action) and within + period of time.
Learners can work in pairs to find and
underline time prepositions and expressions
that tell you about frequency. Work through
some examples to get them started, e.g.
frequency of action = ‘twice a day’, time
preposition = ‘by June 3’. Encourage learners to
record useful time expressions in their
vocabulary notebooks.
■ Elicit other examples learners may know, e.g.
frequency expressions: ‘every 2 hours’,
‘2 hourly’, ‘once’/‘twice’, ‘3 times a day/week’,
and other time prepositions: ‘+ day/date’,
‘within two weeks’, ‘after’, ‘before’.

134
 Nu Module 2 Planning patient care
PAGE 2:5
How to write
precise goals
Task 5
Introduction and curriculum references
to choose formal language and register
appropriate for a care plan that will be read by
other medical staff
to practise writing precise goals
to understand that care plans have their own
vocabulary and how this affects precision of
meaning
ESOL
Wt/L1.2a; Wt/L2.5a; Rw/L1.1a
Notes
■ Set up question 1 for pair or small-group work.
Learners discuss which of the goals are precise
and include all the necessary components and
which are in need of improvement.
■ They then discuss ways of improving the goals
and re-draft them. Learners may need more
information about the patients: Mrs Martin, 52
and obese. Attended an admission clinic for hip
replacement. Mrs Collins, 45, abdominal
hysterectomy. Doris will be discharged
tomorrow after surgery. Mr. Kamel has been
diagnosed with hypotension. If possible,
encourage learners to write their improved
versions on an OHT, so that the results can be
discussed in group evaluation.
If the learner has difficulty
Give learners the goals that need improving. For
each goal, discuss ways of improving it, eliciting
suggestions from the learners and writing them
on the board or an OHT.
135
Task 6
Introduction and curriculum references
to complete a care planning form
to use proofreading to check your work
to choose formal language and register
appropriate for a care plan that will be read by
other medical staff
ESOL
Wt/L1.6a; Wt/L1.7a; Wt/L2.5a
Notes
■ The purpose of this task is to give learners
practice in identifying and discussing nursing
goals for a specific patient, and writing goals in
an appropriate style.
■ For question 1 you will need photocopies of
the two cases in the Resources for the theme,
copies of a blank care form for question 2, and
copies of a checklist for learners to evaluate
their writing for question 3.
■ Set up pair work or small groups. Learners
choose a case study for question 1 and read it,
underlining actual and potential nursing
problems. They then discuss the care in their
pairs/groups and decide on appropriate goals
for the patient.
■ For question 2, give out the blank form.
Learners draft the goals and then work with
other learners for question 3 to evaluate each
other’s writing and give constructive feedback,
e.g. on clarity, use of vocabulary, accuracy of
language and handwriting.
■ Hand out the checklist for learners to complete.
This can form the basis for any re-drafting in
question 4.
If the learner has difficulty
■ Work with learners on one of the cases, first
discussing the patient’s problems and risks and
then discussing and agreeing on three or four
goals.
■ Work with learners to decide on the phrasing
of one or two examples.
■ Then encourage learners to work on the other
goals they discussed.
 Nu Module 2 Planning patient care

Extension PAGE 2:6

■ Based on their nursing experience, learners
plan goals for a patient in their care or a
patient they have cared for. They then write
How to write clear
statements defining the patient’s problem and
stating the goals for nursing care. Encourage
nursing actions 1
them to work with a colleague to evaluate their
writing, using the checklist as above. Task 7
■ Learners write a statement, defining a patient Introduction and curriculum references
problem. They then swap problems with a to complete a care plan form
colleague, and write nursing goals. Encourage
to use proofreading to check your work
pairs to check each other’s work.
to use key features of formal register to write clear
nursing actions
to use an appropriate structure for writing nursing
actions

ESOL
Wt/L2.6a; Wt/L1.7a; Wt/L1.4a

Notes
■ The purpose of the task is to look at the
content that needs to be included in the
‘nursing actions’ section of a care plan and
how to write clear nursing actions.
■ Go through the points in the information
section at the top of the page.
■ Learners can try question 1 in pairs or
individually. As preparation, elicit useful
vocabulary. Ask learners to suggest actions for
each of these categories:
– actions the nurse does to/for the patient,
e.g. record blood pressure
– actions that assist the patient to do
something, e.g. dress
– actions that supervise the patient doing
something, e.g. washing and showering
– actions that involve asking for assistance
from other professionals, e.g. refer to
dietician, liaise with social services
– actions that remind the patient to do
something, e.g. take medication.
■ Learners discuss care for the patient and then
write nursing action statements. Remind them
about:
– using the verb in the imperative form
– conventions for writing dates on care plans
– prepositions, e.g. ‘by’, ‘within’, ‘before’
– time phrases for frequency, e.g. ‘every
4 hours’, ‘4 hourly’.

136
 Nu Module 2 Planning patient care
■ Take feedback and put examples on the board.
■ The example care plan is an extract from a
standard care plan. Use this and the example
standard care plans in the Resources Section to
discuss learners’ experiences of working with
such plans. Review some of the advantages and
disadvantages from the discussion point at the
start of the theme. Direct learners to the tip
and discuss.
137
PAGE 2:7
How to write
nursing actions 2
The aim of question 2 is to develop useful
vocabulary. Learners may need to check the
meaning of some verbs in a dictionary before they
try the task.
Encourage learners to use care plans as a source of
useful vocabulary and make a collection of words,
using the example care plans from the theme and
the Source material and care plans from their
workplace.
For question 3, learners work again on the case
study from Task 6, in the same groups. This time
they discuss and plan nursing actions/
interventions to complete the plan. If necessary,
hand out copies of the cases again.
If the learner has difficulty
■ To develop learners’ vocabulary, get them to
work with the plans in the Source material,
highlighting any verbs they don’t know.
Encourage them to guess the meaning from the
context or check in a dictionary.
■ Also encourage learners to focus on ‘noun +
verb’ collocations – nouns and verbs that
frequently occur together, e.g.
– administer drugs/medications/oxygen
– monitor vital signs – pulse, respiration rate
– liaise with the stoma nurse/dietician.
■ Point out that recording verbs and nouns that
often go together is a useful way of increasing
vocabulary and producing natural sounding
English.
Extension
■ Learners develop care plans for patients in their
care or patients they have cared for previously.
Give them this checklist to think about when
discussing the care:
– actions to prevent or minimise the problem/
risks
– actions likely to get the desired results
– actions to minimise the risk of adverse
responses and increase the likelihood of
beneficial responses.
 Nu Module 2 Planning patient care

■ They then write a complete care plan –

problem, goals and nursing actions – using a
photocopy of the care plan from the Resource
Section.
■ Completed plans can be photocopied or put on
an OHT for constructive feedback and
evaluation.
■ Discuss ways of recording vocabulary for
writing plans, e.g. by category using a chart like
the one for Task 4 extension, or word diagrams
like the one below.

dress
wash

Assist patients to do things

feed themselves

bath
shower
walk

Assist patient to do things

toileting personal hygiene ambulate

■ Discuss other ideas learners have for recording

new vocabulary and what works best for them.
The key is to have a flexible way of recording
words, so that new words can be added as
learners come across them.

138
 Nu Module 2 Planning patient care: Writing care plans Nu 2:1

Focus
Planning care with patients involves:
● identifying problems and setting patient goals
● identifying appropriate nursing actions (interventions) for
meeting the goals
● documenting the care you are planning so other staff can
read it easily.

Planning documents vary from hospital to hospital and may take

the form of individual care plans, standard care plans or both.

Task 1
Read this care plan and circle the words that best describe it.
Style: informative / persuasive
Vocabulary choice: everyday / specialist informal / formal
Style of writing: note form / full sentences

■ Date of writing the Date Nurse’s signature

13/9/04
plan Ana Hurtado
ANA HURTADO
■ Signature of the nurse
Problem: Mr Al Mabsali has difficulty breathing due to an acute asthma
writing the plan – this
is a legal requirement attack that has not responded to normal medication.

■ Actual and potential Goals: For Mr Al Mabsali’s respiratory rate to be within his normal
nursing risks for the
levels, 18–20 breaths per minute, with an oxygen saturation
patient
of 96–98% by 13/9.
■ The goal, aims of the
nursing care, Review:
14/9/04
sometimes as a list
Nursing actions:
■ A list of nursing
actions to achieve ● Administer prescribed nebulisers 2 hourly, monitoring pulse,
the goals respiratory rate and blood pressure.
■ Information written
● Monitor oxygen saturation level to keep between 96–98%,
clearly and precisely and inform medical staff if it falls below 96%.
so that it is accessible
● Inform medical staff if sats not maintained with frequent
for other staff and nebulisers after 8 hours.
easy to read
● Monitor and record pre- and post-nebuliser peak flow.
● Ensure patient is informed about all interventions and has
time to ask questions.

139
 Nu Module 2 Planning patient care: Writing care plans Nu 2:2

How to write a goal statement 1

Nurses need to be able to write clear nursing goals for
patients, including the following components:

Who The person who will perform the action, e.g. the patient

Actions Actions the person must perform, e.g. be able to walk to the day room

Conditions Any special conditions under which the action must be performed,
e.g. walk with a stick

Standard The standard that will be used to measure the success, e.g. three times a day

Time The expected time frame for achieving the goal, e.g. by 13 July

Task 2
Read these nursing goals for an older patient who has
been admitted following a series of falls. Then complete
the chart for each goal.

Goals: Mr Dubrika will be able to walk using a Zimmer frame

from his bed to the day room, three times a day by 2/6.

Goals: Mr Dubrika will indicate using a pain

assessment scale that his knee pain is less
than 2 out of 10, within 20 minutes of
receiving prescribed analgesics.

Goal 1 Goal 2

Who Mr Dubrika

Actions Walk to day room

Conditions

Standard

Time

140 ESOL Rw/L1.2a

 Nu Module 2 Planning patient care: Writing care plans Nu 2:3

How to write a goal statement 2

It is important to write nursing goals in a concise and clear
style.

Task 3
1 Look at the nursing goals for this patient and notice the
bold words that introduce the goals.

Mrs Zanni will communicate her basic needs

using flashcards by 13/1.
For Mrs Zanni to feed herself independently
before discharge.

2 Using the information below, complete the goals for

Tip
Mrs Zanni.
When writing goals for
Who Mrs Zanni patients use these
sentence patterns:
Actions dress herself
Future with will
Conditions supervised by a nurse Mrs Zanni will
demonstrate
Timing by 13/5
knowledge of new
medications before
a For Mrs Zanni discharge.
Infinitive (to + verb)
For Mrs Zanni to
demonstrate
knowledge of new
medications before
Who Mrs Zanni discharge.
Actions walk from the ward to the day room

Conditions unassisted, with a stick

Standard for all meals

Timing before discharge

b Mrs Zanni

141 ESOL Wt/L1.4a

 Nu Module 2 Planning patient care: Writing care plans Nu 2:4

How to get the style right

When writing goals on a care plan, use measurable verbs
(verbs that describe what you expect to see or hear when the
goal is met, e.g. have less pain = state / report less pain). They
help you to stay focused on observable data and tell you how
the patient is progressing towards the desired outcome.

Task 4
Tip
1 The verbs on the right are often used in care plans. Dates on care plans are
Match each everyday verb on the left with its more often recorded like this:
formal equivalent(s) on the right. 12 Jan or 12/1.
observe Check which forms are
a move around communicate used at work.
b do (exercise) demonstrate
c show monitor
d talk verbalise Tip
e say prevent ● Use by + date / specific
f check (vital signs) alleviate event
g watch state by 21/8/04, 2/9 or by
h stop discuss discharge.
● Use within + period of
i lessen (pain) administer
time
j give (medication) perform
within 4 days.
ambulate
within 24 hours of
2 Use some of the verbs from the list above to complete surgery.
the goals for these two patients.
a For Eric to knee exercises assisted by a nurse twice a day.

b To to the bathroom using his stick by June 3.

c To his concerns about moving to a residential care home

with a nurse.

d To Mrs Collins for early signs of haemorrhaging and shock

in first hours post surgery.

e To nausea and vomiting within 24 hours of surgery.

f To skin breakdown and pressure sores due to reduced

mobility after surgery.

g For Mrs Collins to be able to the relationship between

exercise, diet and fluid intake and bowel elimination by discharge.

142 ESOL Wt/L1.4a; Wt/L2.5a; Rw/L2.1a

 Nu Module 2 Planning patient care: Writing care plans Nu 2:5

How to write precise goals

Task 5
Some of these goals are vague and do not specify the
methods of achieving the goals, or provide standards for
evaluating them.

1 Work with a colleague. Discuss which ones need

improvement to make them more precise.
Think about these points.
● Is the goal measurable?
● Is there enough detail about how the goal will be
achieved?
● Is there a time scale?
a For Mrs Smith to accept her diagnosis of breast
cancer.
b Mrs Martin to lose at least 6 kg within 6 weeks.
c For Mr Peters to walk independently along the
corridor 2 days after surgery.
d For Mrs Collins to increase her mobility before
discharge.
e Doris will be able to list equipment to change dressing
by 9/5.
f For Mr Kamel to understand the importance of
maintaining a salt-free diet.
g Mrs Collins will feel less pain after taking prescribed
analgesics.
2 Rewrite any imprecise goals you have identified.

Task 6
1 Your teacher will give you two case studies. Choose one
of them and read it, highlighting any actual or potential
nursing problems and risks for the patient.
2 Then write nursing goals for the patient and complete
parts A and B of the care plan your teacher gives you.
3 Work with a colleague and check each other’s writing
using the checklist your teacher gives you.
4 Review your writing.

143 ESOL Wt/L2.5a; Rw/L1.1a; Wt/L1.6a; Wt/L1.7a; Wt/L1.2a

 Nu Module 2 Planning patient care: Writing care plans Nu 2:6

How to write nursing actions 1

Task 7
Nursing tip
Nursing actions (interventions) also need to be written clearly All care plans must
and precisely and will often contain these components. be signed by the
nurse writing the
plan. During
Date Nurse’s signature supervised practice,
Date of 13/9/04
Ana Hurtado your signature must
writing
ANA HURTADO be countersigned by
the plan
Problem: Mr Al Mabsali has difficulty breathing due to an acute asthma a registered nurse.
attack that has not responded to normal medication.

Goals: For Mr Al Mabsali’s respiratory rate to be within his normal Timings by

levels, 18–20 breaths per minute, with an oxygen saturation which the
of 96–98% by 13/9. nursing action
should be
Review: achieved or
14/o9/04
reviewed
Nursing actions:
● Administer prescribed nebulisers 2 hourly, monitoring pulse, Precise details
respiratory rate and blood pressure. of what the
Verbs in ● Monitor oxygen saturation level to keep between 96–98%, nurse will do
the and inform medical staff if it falls below 96%. for the patient
imperative ● Inform medical staff if sats not maintained with frequent
form nebulisers after 8 hours.
● Monitor and record pre- and post-nebuliser peak flow.
● Ensure patient is informed of all interventions and has time
to ask questions.

1 Work with a colleague and discuss the nursing care these

patients need. Then write four or five nursing actions for
each patient.
Situation 1 Situation 2

Problem: The patient is constipated, with
no bowel movement for 4 days, related to
bed rest and consequent immobility, and
inadequate fluid intake and lack of
balanced diet.
Goals: For the patient to report or
demonstrate bowel movements.
Problem: The patient has been
prescribed bed rest following surgery
with the consequent risk of impaired
skin.
Goals: To maintain intact skin and absence
of redness and signs of pressure sores.

144 ESOL Wt/L1.4a; Wt/L2.6a; Wt/L1.7a

 Nu Module 2 Planning patient care: Writing care plans Nu 2:7

How to write nursing actions 2

2 Look at these examples of standard care plans for
patients recovering from surgery. Complete them using
the verbs below.

administer ensure give introduce maintain

monitor observe

Problem:
(patient’s name) is unable to maintain his/her own safety needs
immediately after surgery; potential haemorrhage; potential
dehydration due to nil by mouth; potential nausea and vomiting

Goal:
For patient to return to full consciousness safely.
To observe for early signs of haemorrhage/shock.
To alleviate nausea and vomiting.
To prevent dehydration.

Interventions:
………….……. and ………….…… airway on return to ward.
………….…… pulse, respiration and BP … hourly until stable.
………….…… patient call bell to hand.
………….…… wound site for oozing.
………….…… fluids, then solids as tolerated.
………….…… patient passes urine.
………….…… anti-emetics as prescribed and ………….…… their effectiveness.

3 Review the nursing goals for the case you
chose for Task 6. Discuss some nursing
actions with a colleague. Then write up the
notes to complete the rest of the care plan
your teacher gave you.
4 Work with a colleague. Check each other’s
writing and then finalise your plan.
Nursing tip
If you are using standard pre-printed
plans, use them critically. Check
them against the patient’s specific
situation; assess what applies, what
doesn’t apply, and what you need to
modify or change according to the
needs of the specific patient.

145
 Nu Module 2 Planning patient care: Writing care plans Nu 2:8

Resources
For Page 2:4, task 4, extension
These verbs are often used in care plans. Put each of them in one
of the categories following the examples. If necessary, look them
up in a dictionary to check their meaning.
Find other examples from care plans in the theme or care plans
from your workplace. If necessary create new categories.

alleviate ambulate brush your hair/teeth demonstrate

describe drink eat explain express minimise
mobilise observe record re-educate relieve
remind shower sit stand wash

mobility educate
walk teach

feelings pain relief

express reduce
verbalise

personal care vital signs

dress monitor

146
 Nu Module 2 Planning patient care: Writing care plans
Resources
For Page 2:5, task 6
CASE STUDY 1
● Female, 31 years.
● Admitted with cerebral concussion,
following a car accident.
● Works full time as a shop assistant.
● ●
Divorced with two children
under 5.
● Her mother looks after children full
time, but is ill at the moment and
unable to look after them; staying
with a neighbour temporarily.
● Anxious about children and says
she’s OK and needs to go home.
Doesn’t want contact to be made
with children’s father.
CASE STUDY 2
● Ahmed Al Mabsali, 18 year old
male, just started university course
in environmental biology.
● Lives in student residence on
campus.
● Asthma started 3 years ago,
contrary to medical advice only
treatment inhaled salbutamol.
● Reluctant to rely on an inhaler;
‘normal people don’t need an
inhaler all the time’.
● Exposure to grass cutting / pollen
on field trip 2 weeks ago
exacerbated condition.
● GP prescribed steroid inhaler but
did not resolve the problem.
147
Nu 2:9
● Complains of bad headache and
says feels dizzy and nauseous.
● Cannula in right arm. IV fluids
running at 30 ml/h.
Bruising to forehead.
● Pulse regular.
● Blood pressure 128/74 mmHg,
respiration 24 breaths per minute,
non-laboured, temp 37°C.
● Pupils equally reactive to light.
● Moves all extremities.
● Afraid of hospital needles.
● Embarrassed about using a bedpan.
● No previous episodes of severe
attacks, but complains of
wheezing in the mornings.
● On admission, very breathless and
unable to complete a sentence.
● Ashen and clammy.
● Given oxygen by mask and
prescribed nebulised bronchilators
and i.v. steroids.
● Pulse rate 110 beats per min.
● Respiration 40 breaths per min.
● Pulse 150.
 Nu Module 2 Planning patient care: Writing care plans Nu 2:10

Resources
Care planning form for Page 2:5, task 6

Patient’s name: Hospital number:

Date of birth:

Date: Nurse’s signature:

A Problem:

B Goal:

Interventions:

Progress and evaluation: Date: Signature:

148
 Nu Module 2 Planning patient care: Writing care plans Nu 2:11

Resources
Feedback form for Page 2:5, task 6

Checklist Yes No Changes to implement

Are the goals clear?

Are the verbs measurable?

Is there a time frame for

evaluating achievement of
the goal?

Are the dates written

correctly?

Are prepositions used

correctly?

Is the handwriting easy

to read?

Has the plan been signed

and dated?

Other comments:

149
150
 Nu Module 2 Planning patient care
PAGE 2:12
Discussing care
Focus
Professional setting
The topic of the theme is discussing options for
patient care. In particular, it builds skills that an
international nurse needs in order to take an
active part in discussions with senior colleagues
about the care he/she is planning, for example
with a supervisor, a mentor or other senior
member of staff on the ward.
The theme develops skills for being proactive in
asking for feedback and then taking an active role
in the discussion by asking questions, checking
and clarifying to ensure that any comments or
suggestions are fully understood.
The theme also focuses on the relationship in UK
nurse education between supervisor and
supervisee, and cultural differences in the
expectations of the roles. In some cultures, the
role of the nurse would be to carry out the
supervisor’s instructions and not to question and
query them, whereas UK nurse education
encourages nurses to think critically, take
initiative and query decisions, even those made
by senior staff.
Materials
Blank cards/sticky notes, e.g. for writing up new
words
Audio cassette player/CD player
Blank cassettes for recording on
Photocopies of Resources for the theme
Dictionaries and medical glossaries
OHP and transparencies (optional)
Learning outcomes/objectives
1 to ask for feedback
2 to follow a supervisor’s feedback on a care plan
3 to recognise different ways of giving advice and
making suggestions and their different
strengths
151
4 to know how to respond to suggestions
appropriately
5 to make sure you understand feedback by
asking questions, asking for repetition and
clarifying
6 to use feedback from a discussion to review the
care you’re planning
Curriculum objectives
ESOL
Lr/L1.1b; Lr/L2.2d; Sd/L1.2b; Sd/L1.3c; Sd/L1.3c;
Lr/L1.3a; Sd/L1.2c
Suggested teaching activities
■ Set the context by asking learners about their
experience of getting feedback from:
– UK colleagues at work – mentors, supervisors,
other nurses, other international nurses
– Colleagues from the country in which he/she
has practised or trained.
Task 1
■ Set up the discussion points for pairs or small
groups, pooling ideas after the discussion. The
aim is to get learners to reflect on their
experience of getting feedback and advice in a
work context.
■ If learners are not in work, encourage them to
reflect on their experience of getting help and
advice when trying to find their way around
UK systems; for example, the social security
system, choosing a school for their children.
■ With learners who have experience of working
in the UK, elicit what they find difficult about
asking for advice or feedback from colleagues,
e.g. staff being too busy, not understanding
what is being said. Encourage them to be as
specific as possible, drawing on their
experience to illustrate their ideas; e.g. I asked
my supervisor for help with … and he was so busy.
I felt he really didn’t have time to deal with me.
 Nu Module 2 Planning patient care
■ With learners who aren’t in work they can
discuss their experience of accessing advice, e.g.
getting advice on housing, schooling for
children.
■ Go through each of the points in the
guidelines. Elicit other phrases for each stage.
Ask for suggestions for completing the speech
bubbles in the photos. Point out that the
learners will get the chance to practise some of
these skills in the tasks in the theme.
152
PAGE 2:13
How to follow
feedback
Task 2 23
Learning objectives and curriculum
references
to extract relevant detail from a discussion about
planning a patient’s care
to use knowledge of the context to predict the
likely content of a discussion about care planning
to practise listening for key words related to the
context
to raise awareness of a supervisor’s role in giving
feedback to nurses he/she is supervising
ESOL
Lr/L1.1b
Notes
■ The purpose of the task is to show how
knowledge of the context helps predict likely
content and vocabulary of a discussion.
■ Before you start, elicit difficulties learners have
when listening, e.g. the speed at which people
speak, difficult/unfamiliar accents, unknown
words, words that seem to run together etc.
This can be done as a class or in groups, with
each group reporting back.
■ For question 1 set up the task for individuals or
pairs. If necessary remind them of the Activity
of Daily Living assessment and its role in
planning nursing care (also see Module 1,
Assessing patient needs).
■ Learners read the information from the ADL
and then discuss and list three or four nursing
actions (interventions) to increase the patient’s
food intake and any benefits for the patient.
Play the audio clip through. Check answers
and encourage learners to compare with their
predictions.
 Nu Module 2 Planning patient care
■ Get learners to read through the items in
questions 3 before playing the audio clip again
so that they know what kind of information
they will be listening for. Also encourage
learners to predict likely vocabulary for a
discussion about care for an older patient, e.g.
nutritional assessment, food intake chart,
supplements etc.
■ Play the audio clip and check answers.
■ For question 4 first discuss the meaning of the
words with the learners. Encourage them to
provide evidence from the discussion to
support their views. As necessary, play the clip
again or photocopy the transcript for the
learners to work with.
■ As follow up set up a short discussion about the
learners’ expectations of the role of the
supervisor in giving feedback, and their
experiences in the UK and in other places
where they have worked. Direct them to the
tip.
If the learner has difficulty
■ Discuss and put some possible nursing actions
up on the board, including the two main ones
from the audio clip. Then elicit and note
benefits for the patient.
■ Learners then listen for and tick any actions
and benefits listed.
■ For question 3 learners can work with the
transcript, underlining the answers. They can
then listen for the information.
Extension
Learners can use the same procedure when
listening to other types of information e.g. to the
news on TV. Encourage them to predict stories
that are likely to come up in the news and words
they think they’ll hear. They then watch and
check.
153
PAGE 2:14
How to respond to
feedback
Task 3 23 27
to listen for different ways of giving advice and
making suggestions and recognising the strength
of the advice or suggestion.
to know the difference in meaning between
‘should’ and ‘could’.
ESOL
Lr/L2.2d
Notes
■ Before you start the task, elicit different
expressions for giving advice. Collect examples
on the board or an OHT and get the learners to
categorise them according to their strength,
e.g. What about …? is just an idea to think
about, but an expression like You should … is an
example of stronger advice.
■ Discuss the information at the top of the page,
pointing out the importance of being able to
recognise different shades of meaning when
deciding what follow-up action to take.
■ The audio clip is the same as for task 2, but this
time the focus is on listening for the words the
supervisor uses as she gives her feedback.
■ Before you play the audio clip, encourage the
learners to predict the missing words, using
their knowledge of the language and what they
remember from the previous listening.
■ Play the audio clip through, pausing after each
suggestion so learners can discuss and check
their answers.
■ Learners can discuss question 2 in pairs.
■ Question 3 provides more practice in listening
to the phrases used to give suggestions. Play
the four extracts, pausing after each one to
discuss the context, problem and tone of the
advice. Then play it again so learners can listen
for the phrases.
■ Learners then practise saying them. Go through
the tip with the learners.
 Nu Module 2 Planning patient care

If the learner has difficulty PAGE 2:15

■ For question 1 put the phrases on the board so
learners can slot them into the right place as
they listen.
How to respond to
■ Encourage learners to work in pairs to look
through the transcript for 3.1 and 3.3 and
suggestions
highlight phrases used to give strong advice
and for suggesting ideas. Task 4 28

■ Learners can then discuss and write rules Introduction and curriculum references
explaining how to use the verbs ‘should’ and to discuss and agree on changes to a care plan
‘could’ and expressions ‘have you thought
to give reasons to explain why you’re rejecting a
of …?’ or ‘what about …?’
suggestion
Examples:
to respond to suggestions, by accepting, accepting
Have you thought of …? reluctantly and rejecting politely.
When to use it
ESOL
Suggest a possible way of doing something
Sd/L1.2b
How to form it:
Have you thought of + verb + ing
Notes
Example: Have you thought of bringing in the
physio? ■ Elicit phrases the learners already know for
accepting suggestions and rejecting them.
Should ■ Put these phrases for rejecting suggestions on
When to use it: the board and discuss differences in strength.
Give strong advice That won’t work.
How to form it: I’m not sure that would work.
Should + verb I don’t think that’s such a good idea.
Example: You should bring in the physio. That’s no good.
■ Point out how you can soften a rejection by
■ For question 3 give the learners some key using words like ‘I’m not sure…’, ‘I don’t
words from each of the extracts and ask them think…’, and the importance of rejecting
to predict what it is about. politely for keeping the tone of the discussion
co-operative.
Example for extract 1:
■ Learners can work in pairs for question 1
Mr Fasad his mother what she wants
discussing the phrases and categorise them.
what he wants discuss treatment
Direct learners to the tip on rejecting
interpreter
suggestions.
■ Play the audio clip to check their predictions.
■ For question 2 encourage learners to use their
Extension nursing experience to create a context for the
Encourage learners to ask colleagues / friends and role play. Allow time for learners to make brief
family members who work about expressions they notes about the patient and his/her care.
use to make suggestions or give stronger advice, ■ In question 3 learners take turns to act out a
and share them with the group. discussion following the discussion plan. As
necessary, ask the learners to suggest phrases
for each stage of the discussion.

154
 Nu Module 2 Planning patient care

■ When you give feedback, focus your comments
on these points:
(1) How well the learners used phrases for:
making suggestions
accepting them
rejecting them and giving reasons.
(2) How effectively they maintained a
co-operative tone in the discussion.
■ As follow up direct learners to the nursing tip.
If the learner has difficulty
■ Play them again, and this time learners follow
the phrases on the page and mark the links
they hear (elisions) in each phrase. You may
need to play each phrase several times. Hand
out a copy of the transcript to check answers.
■ If possible learners record the role play for
question 3 for evaluation.
■ For learners who are in work, ask them to
reflect on their experience of getting feedback
from a colleague.

■ For question 1 put the phrases on cards so that
learners can physically move them around as
they categorise them.
■ Using the conversation plan for question 3,
work with the learners to build up a possible
discussion. Elicit suggestions line by line and
record them on the board or an OHT. The
learners can then work in pairs to practise the
discussion.
■ If learners have difficulty coming up with
contexts for the role play, suggest an idea like
this to start them off. Example:
Ask them to think about and make notes on
these points.
What happened.
How they felt about their contribution to
the discussion.
What went well, what went less well.
What they learnt from the experience that
would be useful in future feedback
discussions.

A 65-year-old male patient with problems

sleeping. He wakes up several times a night
to urinate, and complains he can’t get back
to sleep because of the noise from the
nurses’ room and the observations of other
patients through the night.

Extension
■ Work on the learners’ pronunciation for
reacting to suggestions, focusing on how some
words run together (elide), e.g. words ending in
a consonant that are followed by a word
beginning with a vowel, e.g. good idea. This
can be a problem for ESOL learners as they
think they hear a word they don’t know, when
in fact, it’s just two words they know very well
that have been run together. Demonstrate a
couple of examples:
She’ll agree to that.
I’ll think about that.
■ Play the audio clip for the extension sentence
by sentence, asking the learners to say how
many words they think they hear in each
phrase.

155
 Nu Module 2 Planning patient care
PAGE 2:16
How to make sure
you understand
feedback
Task 5 29
Learning objectives and curriculum
references
to use strategies to clarify and confirm
understanding
to use a range of ways of asking for clarification
and repetition
to ask questions for getting more detail
to raise issues about the roles of supervisors and
supervisees in a UK nursing context.
ESOL
Lr/L1.3a
Notes
■ Ask learners for phrases they would use to:
ask for repetition
check they’ve understood
ask for clarification when they don’t
understand.
■ Put some of their suggestions up on the
board/OHT to check against audio clip they
are going to hear.
■ The audio clip is an extract from the audio
about the care for Mr Dubrika from task 2.
Check what learners remember about the
discussion about his care.
■ Play the audio through, pausing for learners to
complete the items and then match them with
the speaker’s intention in question 2.
■ Set up question 3 for pairs. Learners discuss and
decide on questions for each situation. Pool
questions and encourage learners to record
useful questions.
■ Discuss the information in the nursing tip.
■ Ask about similarities and differences in other
countries where they have worked.
156
If the learner has difficulty
■ For question 3, work with the learners and
■
elicit suggestions for each situation.
Alternatively, photocopy and cut up the answer
for question 3. Learners then group them under
these headings:
asking for more detail
asking for repetition if you miss information
clarifying information if you don’t really
understand.
Extension
■ For question 3 learners discuss how to respond
to the suggestions and advice in the four
extracts and role play them for additional
practice.
■ Encourage learners to collect expressions they
hear at work for checking, clarifying
information and asking for repetition.
■ Encourage them to note any useful ones to
share with the class.
■ Set this reflection task for small groups to
encourage discussion about relationships
between a supervisor and the supervisee in UK
nurse education, with each group reporting
back their views.
(1) What differences have you noticed
amongst nurses doing supervised practice
and newly qualified nurses and how they
interact with senior staff?
(2) In your country how usual would it be
for a nurse to question senior staff’s
decisions and advice?
How would it be perceived by:
the nurse?
the senior colleague?
other members in the care team?
(3) In what ways do you think you will need
to adapt your behaviour and way of relating
to colleagues to fit into the UK nursing
context?
 Nu Module 2 Planning patient care

PAGE 2:17 communication and examples where this was

less effective. After each role play, allow time

How to be for feedback, eliciting from the learners what

worked and what didn’t work and how they
felt about the experience.
proactive in a ■ Encourage learners to record their role plays
and play it back later for reflection and
discussion about improvement.

care If the learners have difficulty

■ For question 3 build up the discussion with the
learners, following the steps in the
Task 6 conversation plan below.
Learning objectives and curriculum ■ Photocopy the plan and give out copies.
references
■ Before the role play, work with the learners to
to ask for feedback on a care plan and make discuss phrases for each of the steps in the
suggestions discussion. Learners then prepare and act out a
to respond appropriately to suggestions discussion following the steps in the
conversation plan, taking turns with the roles.
to use a range of questions for asking for more
information and getting repetition and Nurse Colleague
clarification
Ask for feedback from
to use information from the discussion about care your colleague
to update a care plan Make constructive
ESOL comments on the
plan
Sd/L1.2b; Lr/L1.3a; Sd/L1.2c
Agree to any changes
Make your first
Notes
suggestion
■ This role play task brings together skills from
Ask questions to ensure
this theme and also from the theme Writing
you have all the
care plans.
information you need
■ Before starting the task, you’ll need ———
photocopies of the ADL for Mr Dubrika and the Accept or reject + reason
care plan in the Resources for the theme. Make another
■ For question 1 hand out the ADL and allow suggestion
time for the learners to read the form, Ask questions to ensure
underlining the nursing problems and risks for you have all the
Mr Dubrika. Encourage learners to share their information you need
ideas with a partner. ———
■ Hand out the blank care plans for the learners Accept or reject + reason
to complete (2 per learner). Thank your colleague
■ Review principals for writing clear goals and
nursing actions, e.g. being specific, using Extension
measurable verbs. ■ Learners can develop role plays based on their
experience of planning care for patients. For
■ Set up question 3 as pair work. Learners
this task you need photocopies of a blank
exchange plans. Before the role play, allow time
patient assessment form from the Resources for
for learners to evaluate the plan and come up
module 1, theme Assessing patient needs, or an
with two or three other additional suggestions.
assessment form used in the learner’s
■ Learners then take turns to act out the role of workplace. Again learners can record the role
the nurse and supervisor. During the role play plays for reflection and improvement.
circulate, making note of examples of effective

157
 Nu Module 2 Planning patient care

■ Use the ADL form for Mr Dubrika to build

vocabulary. Encourage the learners to read
through and highlight any words or
expressions they don’t know.
■ Encourage the learners to guess the meaning of
the word by looking for clues in the sentence
with the unknown word and in the sentences
that come before and after it. If they still aren’t
sure of the meaning, or want to check, they
can then look up the word in a dictionary.
■ Discuss ways of recording new words, e.g.
(1) Writing the word and its definition next
to it.
Deterioration (noun) = the action of getting
worse.
(2) Then write an example that relates to the
learner’s own situation.
I’m afraid there’s been a deterioration in Orjona’s
condition overnight.

158
 Nu Module 2 Planning patient care: Discussing care Nu 2:12

Focus
When you are planning a patient’s care, it is useful to get
feedback and input on your plan from your supervisor or
other experienced staff in the care team.

Task 1
Discuss these points with a colleague.

1 Do you get more or less feedback as a nurse in the UK or in

other countries where you have worked?
2 If you need feedback on the care you are planning for a
patient who would you approach?
3 What kind of input would you expect to receive?

Even if the other person is busy, ask for help.

If you’ve got a moment, I’d appreciate some feedback on… .
I think you should…

Why don’t you …?

I’m not sure

that would work.
What do you
mean exactly?
Well, you could …

Yes, I’ll think

about that.

■ Listen carefully to how people give feedback as the words they use can have
different shades of meaning.
Why don’t you …? You could … (suggestions to think about)
You should ... (strong advice you need to act on)
■ Ask questions and clarify to make sure you have enough information to decide
whether to accept or reject the feedback.
■ Use appropriate phrases to accept or reject the other person’s suggestions.
■ At the end of the discussion, thank the other person for their help.

159
 Nu Module 2 Planning patient care: Discussing care Nu 2:13

How to follow feedback

When asking for feedback on your plan, listen carefully for
key words that tell about changes you need to make and
suggestions that need to be added.

Task 2
1 A nurse is planning care
for an older patient who Task of living Usual behaviour Changes related to present condition
has been admitted,
Eating and Poor appetite. Has eaten and drunk very little
following a series of falls. drinking Has lost weight. since admission. Says he
Read an extract from the
Says he ‘can’t doesn’t like hospital food.
patient’s ADL assessment.
face cooking’
Make a list of three or four
nursing actions to increase
his food intake.
2 Listen to the nurse discussing the patient’s care with her
supervisor. What other ideas does she have for the Nursing tip
23
patient’s care? In UK nurse education
the role of the
3 Listen again and answer these more detailed questions.
supervisor in giving
a What aspect of the patient’s care is the supervisor
feedback is to open up
unhappy about? the nurse’s ideas,
b What does the nurse agree to do about it? encouraging him or her
c The supervisor suggests involving another member of to come up with the
the care team. Who is it and what kind of input can ideas rather than telling
she give? him/her directly what
d Does the nurse accept or reject the suggestion? to do.
e What other suggestion does she make?
f What would the benefits be for a patient like Mr
Dubrika?
g Does the nurse agree to add the suggestion to the
plan?
4 Tick the words that best describe the supervisor’s style of
giving feedback.
authoritarian
critical

supportive prescriptive

160 ESOL Lr/L1.1b

 Nu Module 2 Planning patient care: Discussing care Nu 2:14

How to respond to feedback

When colleagues give their ideas on improving care, you
will often hear verbs like should and could or expressions like
What about …? Listen carefully for the words they use as
they can express very different shades of meaning.

I think you should involve What about involving

social services. (strong social services? (an idea
advice you need to act on) for you to think about)

Task 3
1 Listen again to the discussion about Mr Dubrika. What
23 does the supervisor say to give her ideas for his care?
Complete the missing words.

a You get one done as soon as you can.

b getting some input from the dietician?

c If he’s not eating, a nutritional supplement?

d see what she ?

2 Look through her ideas again.

Which ones are suggestions for the nurse to consider?
Which one is strong advice that needs urgent action? Tip
● should = strong
3 Listen to extracts in which a senior nurse gives feedback
on the care being planned for patients. What is her advice about what to
do.
24 intention in each extract? Write the letter beside the
You should check his obs
27 extract.
every 2 hours.
A Give strong advice B Make a suggestion ● could = a suggestion
Extract 1 Extract 2 to think about.
You could speak to the
Extract 3 Extract 4 physio if you’re worried.

161 ESOL Lr/L2.2d

 Nu Module 2 Planning patient care: Discussing care Nu 2:15

How to respond to Nursing tip

suggestions ● When you are at

work, listen carefully
for expressions that
When discussing options for a patient’s care, you need to staff use to:
know how to accept suggestions and also how to reject – ask for suggestions
them politely in order to keep the tone of the discussion – make suggestions
– accept or reject
with your supervisor co-operative.
them.
● Make a note of the
Task 4 most frequently used
expressions and share
1 Look through these phrases for reacting to suggestions.
them with the class.
28 Discuss which ones have these purposes.
● Accept the suggestion

● Reject politely
a OK. I’ll give it a try. b I’m not sure if it’d work.
● Accept reluctantly

c That’s a good idea. d e

I could try that, but I don’t I don’t think she’ll
think she’ll be happy about it. agree to that.

f OK. I’ll add it to the plan. g Right. I’ll follow that up. h I suppose I could do that.

2 Practise asking a senior colleague for feedback on care

you are planning for a patient.
Make some brief notes on these points, using your
experience of planning care for patients.
● the patient’s problems:
● the nursing goals:
● the nursing interventions you’re planning:
● your concerns and reasons for seeking advice:

3 Act out a discussion following the plan below.

Tip
Nurse: Explain the problem and ask for a suggestion When you reject a
suggestion, explain why
you are rejecting it.
Colleague: Give your suggestion + reasons/benefits I don’t think that would
work. She’s very reluctant
to take a lot of
Nurse: Accept or reject medication.

162 ESOL Sd/L1.2b

 Nu Module 2 Planning patient care: Discussing care Nu 2:16

How to make sure you

understand feedback Nursing tip
UK nurse education
places emphasis on
In order to assess whether the care being proposed is developing the ability
appropriate for the patient, you need to make sure you have to think critically and
all the facts. You can do this by: take initiative. This
involves being
● asking for more detail
proactive when
● asking for repetition if you miss information
receiving feedback
● clarifying information if you don’t really understand.
from other staff; for
example, asking
Task 5 questions and even
questioning advice
1 Listen to an extract from the discussion about Mr Dubrika’s they give you.
29 care. Complete the questions the nurse asks her supervisor.

a Fiona O’Grady? c good as a snack between meals?

b a supplement like Polycal? d the name ?

2 What’s the purpose of each of her questions? Match them

with the bullet points in the information above.
3 Kathy Bailey, aged 75, is recovering from a severe chest
infection, but is reluctant to mobilise due to pain from her
arthritis.
Discuss each suggestion by asking questions and clarifying
to make sure you have all the information you need.
a If she has a lot of pain in the
joints in her hands, you could Best one?
try a pain relief cream.

b Have you thought about relaxation What’s she talking

techniques? That can be a help about? Relaxation
for patients with chronic pain. techniques!

c You could increase her pain relief to Dose!

2 paracetamol, 4 times a day, but Frequency? A pain
you’ll need to monitor the effects. assessment tool?

d Until she’s more mobile, it might

be an idea to get the physio to I don’t understand,
give her some exercises to stop joints seizing up!
her joints seizing up.

163 ESOL Lr/L1.3a

 Nu Module 2 Planning patient care: Discussing care Nu 2:17

How to be proactive in a
discussion about care
This task brings together all the skills from the theme in a
role play.

Task 6
1 Your teacher will give you Mr Dubrika’s ADL (Activities of
Daily Living) assessment. Read through the form and
highlight the nursing problems and risks for the patient.
2 Now look at the problems and risks you have identified
and decide on one or two goals for Mr Dubrika. Then
plan some nursing actions to achieve your goals.
Complete the care planning form your teacher gives you.
3 Work with a colleague. Exchange plans with your
colleague and take turns to ask for feedback on your plan
and discuss other suggestions for Mr Dubrika’s nursing
care.
4 Prepare your roles and then act out the discussion.

Nurse role Supervisor’s role

Be proactive in the discussion, asking Be supportive in the discussion.

questions, checking, clarifying. ● Give feedback on the nurse’s plan.
● Ask for feedback on your plan, giving ● Make any other suggestion you have
relevant details about the patient and for the patient’s care.
your concerns about his/her care.
● Be prepared to answer any questions
● Respond to any comments on your the nurse has.
plan.
● Ask your colleague for other
suggestions.
● Discuss each suggestion, asking
questions and clarifying to make sure
you fully understand.
● Accept or reject each suggestion.
● Thank your supervisor for his/her help.

5 Update your care plan for Mr Dubrika.

164 ESOL Sd/L1.2b;skills

Lr/L1.3a;
reference
Sd/L1.2c
 Nu Module 2 Planning patient care: Discussing care Nu 2:18

Resources
ADL for Mr Dubrika for Page 2:17, task 6

Task of living Usual behaviour Changes related to present condition

Communication Hearing good. Wears glasses but complains they Alert and orientated, but appears
are ineffective now due to deterioration in withdrawn and seldom interacts with
eyesight, related to ongoing macular degeneration. staff and other patients unless spoken to.

Breathing Says he gets breathless going up and down No identified problems.

stairs.
No history of smoking.

Eating and Poor appetite. Says he doesn’t like hospital food.

Drinking Has lost weight and clothes have become ill Has eaten and drunk very little since
fitting. Says he ‘can’t be bothered to cook any admission.
more’.

Eliminating Fully continent. No bowel movement since admission.

Bowel movements have become more irregular since
wife died - 2/3 times weekly down to once every
7/8 days.

Personal care Personal hygiene neglected since death of wife. Complains of a dry mouth and inflamed
and hygiene Wears dentures that are badly fitting and make gums and has halitosis which he says he
his mouth sore. finds very embarrassing.

Mobilising Recently re-housed in ground floor flat with
small garden. Mobility restricted due to arthritis
in his knees, but able to move around the flat
and garden with a stick. Since death of his
wife seldom goes beyond the house.
Weekly shop done by neighbour.
Reluctant to mobilise and spends most of
the day sitting in his chair by his bed.
Says the pain from his arthritis ‘gets him
down’. Takes 1 tablet of paracetamol 4
times a day.

Working playing According to daughter (married and living in No interaction with other patients and
Spain) sociable and outgoing before wife died, prefers to take his meals on his own by
but now seldom sees friends and family. his bed. Says he used to be very
Used to be very active with lots of interests: sociable, but these days ‘can’t face
● keen gardener and says he has ‘green people’.
fingers’.
● Used to play a lot of cards.
● 2 years ago bought a computer and learnt to
use e-mail so he could communicate with his
grandchildren but untouched since wife’s
death.

Expressing Wife died of a coronary thrombosis a year ago Says he thinks about his wife all the
sexuality and is still grieving for her. Has become very time.
isolated.

Sleeping Poor sleep patterns since death of wife. Gets
up 3 or 4 times a night and listens to the
radio.
No more than 3/4 hours of quality sleep. Says
he feels ‘tired and listless’ all the time.
Says he can’t sleep because of noise of
other patients. Very concerned to get back
home as soon as possible.

165
 Nu Module 2 Planning patient care: Discussing care Nu 2:19

Resources
Care planning form for Page 2:17, task 6

Name

Problem

Goal

Care planned

166
 Nu Module 2 Planning patient care
PAGE 2:20
Dealing with a deterioration in a
patient’s condition
Professional setting
The topic of this theme is planning and
implementing nursing care when a patient’s
condition unexpectedly deteriorates, e.g. a patient
who develops sudden breathing problems or
haemorrhages from a wound some days after
surgery.
The purpose of this page is to introduce skills a
nurse would need to:
■ assess the situation quickly
■ plan and implement nursing care to stabilise
the patient’s condition
■ ask for assistance from other staff.
The theme also develops skills for reassuring a
distressed patient.
Materials
Blank cards/sticky notes, e.g. for writing up new
words
Audio cassette/CD player
Blank cassettes
OHP and transparencies (optional)
Photocopies of the resources for the theme
Dictionaries and material glossaries
Learning outcomes/objectives
1 to be able to ask a colleague for assistance,
giving a clear update on changes in the
patient’s condition and nursing actions taken
to stabilise the patient
2 to use tenses correctly when giving an update
3 to know how to reassure a patient who is
distressed or frightened
4 to know how to alter the tone of your voice to
sound calm and reassuring
167
Curriculum objectives
ESOL
Lr/L2.2d; Lr/L1.2b; Sc/L1.3a; Lr/L1.6c; Sd/L2.5a;
Sd/L2.2d; Sc/L2.1a
Focus
30
Suggested teaching activities
■ Set the context by discussing learners’
experience of dealing with unexpected medical
complications and setbacks. Focus on the kind
of complications/setbacks that can occur on a
surgical ward after an uneventful initial post-
operative recovery, rather than full life-
threatening emergencies.
■ Discuss how possible it is to apply principles of
goal setting and planning in nursing situations
that require immediate responses.
■ Set up small groups to discuss the challenge of
planning and implementing care when dealing
with a situation in which a patient’s condition
suddenly deteriorates. Encourage learners to
draw on their own experience and the nursing
context in their country.
■ Learners can then think about specific
challenges when planning and implementing
this type of urgent care in a UK context, e.g.
different ways of doing things, not knowing
what to say to patients who are in a very
distressed state, etc. Take feedback from each
group.
Task 1
■ The aim of the audio clip is to set the scene for
the theme. The audio demonstrates how not to
deal with an unexpected complication – a bleed
from an incision after surgery.
■ Play the audio clip through for general
comprehension and elicit answers for
question 1a.
 Nu Module 2 Planning patient care
■ Elicit adjectives for describing how the patient
feels, e.g. distressed, frightened, worried that
■
her operation has gone wrong.
Set up question 1b for small groups, with each
group reporting back their results. Play the
audio clip through again as necessary. There are
no right answers but learners may raise some of
these points:
– nurse left the patient alone while she fetched
things she needed, rather than getting help
from a colleague
– her impatient unsympathetic tone
– the nurse failed to explain what is
happening, going to happen and how the
care is going to help.
■ Go through the guidelines and discuss why
each of them is important when dealing with
patients whose condition unexpectedly
deteriorates.
■ Learners discuss how using the strategies in the
guidelines could have helped the nurse deal
with the situation more effectively, and things
she could have said and done differently.
168
PAGE 2:21
How to ask for
assistance 1
Task 2 31 32
Introduction and curriculum references
to know how to request assistance
to know how to update a colleague on changes in
a patient’s condition
to recognise how the present perfect and present
tenses are used in an update
to recognise and use the right level of formality
and specialist vocabulary in discussions between
nursing staff about patient care
ESOL
Lr/L2.2d; Lr/L1.2b
Notes
■ Discuss differences in planning care for a newly
admitted patient and a patient whose
condition suddenly deteriorates, e.g. the speed
at which decisions have to be made.
■ For question 1, learners use the photo and the
patient information to assess how to deal with
the situation. Learners work individually or in
pairs. Explain the purpose of the time limit – to
simulate as far as possible the reality of having
to think on your feet and plan quickly. Take
feedback and discuss ideas for care.
■ Play the audio clip through to check and
compare with the ideas that were suggested by
learners.
■ Set question 2 and play just the opening part of
the audio clip, pausing to give learners time to
note the actual words used to ask for help.
Elicit other expressions for asking for
assistance.
■ Discuss why the nurse uses medical terms to
describe the patient’s symptoms e.g. more
specific, typical of expert interaction.
■ Discuss the importance of being able to spell
professional words, especially those that are
recorded on medical forms and notes;
encourage learners to keep a spelling glossary.
 Nu Module 2 Planning patient care

■ Discuss the meaning of the terms and how
these symptoms would be expressed in
everyday language, e.g. ‘has difficulties
breathing’, ‘looks blue around the mouth’. The
purpose of questions 4 and 5 is to focus on
how the nurse uses tenses in his update: the
present perfect (have/has + participle) for
actions that have been completed, and the
present tense to describe the patient’s
condition and symptoms.
■ For question 4, ask learners to tick the actions
the nurse has already taken, based on their
recollection of the conversation. Then play the
audio clip to check.
■ For question 5, play just the first part of the
audio clip in which the nurse gives the update.
Pause so that learners can complete the missing
words.
If the learner has difficulty
■ To review tenses, learners can work with the
transcript, underlining the verbs used by the
nurse as he updates his colleague. Then discuss
the use of tenses – present perfect for actions
that have been completed; present tense to
describe the patient’s condition/
symptoms.
■ Learners who need additional practice with
basic tenses can be referred to exercises on verb
tenses in a good grammar book.
■ Discuss the importance of pronunciation and
knowing which part of the word (syllable) is
said more strongly (stressed). Demonstrate with
the example in the chart, cyanosis. Say it
slowly, breaking it down into syllables, i.e. sy-a-
nos-is had four syllables. Say it again and mark
the stressed syllable sy-a-nos-is.
■ Play the audio clip for question 3 so that
learners can listen for the number of syllables
in each word, and then play it again so that
learners can underline the stressed syllable.
■ Learners then practise saying the words with
the correct stress.
■ Discuss the meanings of the prefixes ‘hyper’
(high) and ‘hypo’ (low), common in medical
vocabulary and ask learners for other medical
words they know.
■ Ask learners about other common prefixes and
elicit words they know, for example, ‘anti’ and
‘antibiotic’, ‘antibody’.

Extension
■ Build up useful medical vocabulary for
discussions with colleagues about patient’s
symptoms, e.g. for breathing problems –
dyspnoea (noun) – and for elevated body
temperature – pyrexia (noun) – and know how
they are pronounced.
■ For the extension task you will need
photocopies of the vocabulary development
task in the Resources for the theme, a copy of
the definitions for question 1, the audio clip
(track 32) the words for pronunciation work
and dictionaries and/or medical glossaries.
■ Learners work individually or in pairs to match
definitions and nouns for question 1.
■ Learners then complete the adjectives in
question 2, following the examples and using a
medical glossary to check.

169
 Nu Module 2 Planning patient care
PAGE 2:22
How to ask for
assistance 2
Task 3
Introduction and curriculum references
to practise giving a concise and clear update
to use medical vocabulary to describe changes in
the patient’s condition
to express clearly statements of fact about nursing
actions taken and changes in the patient’s
condition
ESOL
Sc/L1.3a; Lr/L1.2b
Notes
■ The idea of task 3 is to simulate as far as
possible the reality of planning and
implementing care when the nurse has to
respond to a deterioration in a patient’s
medical condition and quickly plan and
implement care.
■ Set up pairs for the role-play. Learners choose
one of the tasks. Set a time limit for learners to
discuss the priorities for treating the patient
and how to deal with the situation. Encourage
learners to use their experience to develop the
details of the content for the role-play.
■ Direct attention to the tip.
■ For question 2, learners work in pairs and act
out the conversation, following the steps in the
flow chart. Elicit useful phrases for each step in
the conversation as necessary, e.g. explaining
your concerns – ‘I’m very worried about …’;
asking for assistance – ‘Do you think I should
...?’, ‘What do you think would be best?’, ‘I’m
not sure what to do about … What would you
suggest?’. Give feedback on:
– the clarity and brevity of the update
– how well learners used medical terms to
explain the patient’s symptoms/condition
– the use of verb tenses in the update, e.g.
present perfect and present tenses.
If the learner has difficulty
■ For question 2, work with learners to build up
the role-play for one of the situations, eliciting
what learners would say at each stage and
170
recording the suggestions as a model
conversation on the board / an OHT. Learners
■
can then practise the conversation.
Learners then work on the other situation to
■
develop a similar conversation.
Check learners are able to recognise short forms
with the present perfect tense and pronounce
them. Demonstrate with examples like these.
I have taken her pulse. ➞ I’ve taken her pulse.
Her breathing has improved. ➞
Her breathing’s improved.
The oxygen has been increased to 10 litres. ➞
The oxygen’s been increased to 10 litres.
She has vomited twice. ➞ She’s vomited twice.
■ Learners can then practise saying the short
forms.
■ Learners who would benefit from a review of
irregular past participles (e.g. rung, spoken)
should be referred to a good grammar book,
which will normally have a listing of past
participles.
Extension
■ If possible, learners record their role-plays,
giving each other constructive criticism and
suggestions for improvement.
■ Ask learners to collect examples of standard
care plans / care guides used in their workplace
to provide guidance for dealing with medical
conditions requiring urgent treatment, e.g.
hypoglycaemia.
■ Learners then discuss care for such a patient,
and act out a similar role-play, updating a
colleague on the deterioration in the patient’s
condition and the care they have implemented.
 Nu Module 2 Planning patient care
PAGE 2:23
How to reassure
and calm a
patient 1
Task 4 31
Introduction and curriculum references
to use different strategies to reassure a patient,
including appropriate body language
to understand the concerns expressed by the
patient and be able to sympathise and respond
appropriately
to be able to recognise feelings as expressed
through intonation and pitch and vocabulary
ESOL
Lr/L1.6c; Lr/L1.2d; Sd/L2.5a
Notes
■ Before starting the task, set up groups and ask
learners to discuss and make a list of things
they would do and say to reassure a distressed
patient. Groups report back, sharing their ideas.
■ Learners can then read the guidelines and
compare with their ideas.
■ Go through the points in the guidelines. Draw
out any points they are surprised about or any
differences in learners’ own cultures, e.g. the
amount of information patients feel
comfortable with, the amount of physical
contact that is appropriate.
■ Draw attention to the tip.
■ For question 2, play the audio clip from task 2
(track 31) again, but this time focus on the
phrases the senior nurse uses to reassure the
patient. Pause so that learners can hear exactly
what she says and focus on the intonation.
Elicit other expressions learners may have
heard on the ward and encourage them to start
a page in their vocabulary notebooks for useful
phrases for reassuring patients.
171
■ When checking answers, focus on the use of
‘just’, e.g. in ‘Just breathe through the mask.’
Also focus on the different verb tenses the
nurse uses as she tells the patient what is
happening and what is going to happen:
– present continuous (is/are verb + ing), e.g.
You’re doing really well.
– Is/are going to + verb, e.g. we’re going to give
you some more oxygen and get you sitting up.
– Will + verb, Bala will stay here with you.
■ It may be useful to hand out a copy of the
transcript so that learners can find and
highlight examples.
If the learner has difficulty
■ Write the reassuring phrases from the transcript
on to cards and hand them out so that learners
can match them with the points in the
guidelines. As necessary, work through a few
examples with the learners to get them started.
■ Ask learners for examples from their experience
of situations where a patient’s medical
condition unexpectedly deteriorated. Elicit
ideas for reassuring the patient. Learners then
act out the role-play in pairs.
■ When taking feedback, ask learners to reflect
on how they felt as the patient and what
worked and what did not work.
Extension
■ Encourage learners to listen for expressions for
reassuring that they hear at work, and/or
discuss with their mentor or colleague any
strategies he/she uses to reassure patients and
which ones work best. Share ideas with the
class.
■ Build up vocabulary for talking about breathing
problems. Elicit words learners know, e.g.
wheezing, short of breath. Learners can record
them as a word diagram and add words as they
come across them.
 Nu Module 2 Planning patient care

PAGE 2:24 ■ Learners can work in pairs to prepare their own

critical incident based on situations they have

How to reassure dealt with during their nursing careers. They

and calm a
patient 2
Task 5
Introduction and curriculum references
to develop awareness of cultural differences in
choosing strategies for reassuring patients
to know how to adapt your behaviour to patients
with different cultural preferences
to use different strategies to reassure a patient,
including appropriate body language
then exchange incidents with other pairs and
discuss the incident, using the points listed
below to guide the discussion.
■ Explain what happened.
■ Analyse how the incident would have been
seen from the perspective of the nurse and the
patient.
■ Explain the nature of the cultural
misunderstanding.
■ Suggest how the nurse could have dealt with
the situation more sensitively.

ESOL
Lr/L1.2d; Sd/L2.5a

Notes
■ Set up question 1 as a group discussion, where
possible grouping learners from the same
culture together. Each group reports back the
results of their discussion.
■ Set up question 2 as pair work / group work,
with different pairs / groups working on
different situations. The point is to get learners
to look at the situation from both the nurse’s
and patient’s perspective. Groups report back
their analysis of the situation and alternative
ways of dealing with it.

If the learner has difficulty

Discuss one or two of the incidents with the
learners, getting them to look at the situation
from the nurse’s and patient’s perspectives,
identifying the cultural misunderstanding and
suggesting an alternative way of dealing with the
situation.

Extension
■ Set this discussion point. Ask learners to
describe any situations they know about when
the wrong way of reassuring a patient actually
made the problem worse.
■ Learners can prepare a checklist / guidelines for
hospital staff for dealing with cultures they
have experience of nursing. This can be done
in class or for independent study.

172
 Nu Module 2 Planning patient care

PAGE 2:25 ■ Play the audio clip through again, pausing so

learners can mark the words or parts of words

How to sound that the speaker stresses to give each phrase a

calming regular beat. (See the marked-up
transcript.)
reassuring ■ Play the audio clip a couple more times, so that
the learners can check.
Task 6 33 34
■ Learners practise the phrases in pairs. If
Introduction and curriculum references possible they should record different versions
to recognise how stress, intonation and pitch can and evaluate each other’s attempts and suggest
indicate a speaker’s attitude improvements, e.g. Try saying it slower. Try to
make your voice sound lower.
to recognise the degree of formality by listening
to a speaker’s use of register and be able to ■ Direct them to the tip. Also point out that
respond appropriately when adopting a reassuring tone, it is better to
use shorter sentences.
to use stress and intonation and pitch correctly
when reassuring patients If the learner has difficulty
■ Hand out the marked-up transcript for question
ESOL
2 so that learners can follow the marks on the
Sc/L2.1a; Lr/L1.2b; Lr/L2.5a
transcripts when you play the audio clip. They
can then use the transcript to practise saying
Notes the sentences.
■ This task is designed to give learners practice in ■ When evaluating each other’s attempts, ask
speaking in a reassuring and calm tone of learners to think about these points:
voice.
– Was it too fast / too slow / OK?
■ Discuss how learners make their voice sound – Was the pitch of the voice too low /
more reassuring in their own language, e.g. get too high / about right?
them to think about the pitch of the voice, – Were the right words stressed to give the
volume, speed etc. phrases a regular calming beat?
■ Play the audio clip for question 1. For each
Extension
item, learners identify the version that sounds
more reassuring and elicit why one sounds Learners can think of things to say to reassure the
more reassuring than the other. patients in the situations for question 3 and
practise them in pairs, recording and evaluating
■ Play the audio clip again, this time asking
their attempts using the criteria above, and then
learners to listen to the reassuring version in
improving them.
each pair, and practise saying it.
■ In question 2, learners practise sounding
reassuring. Before you play the audio clip, write
these phrases on the board and say them in a
calm reassuring tone, with a slightly lower
pitch than usual and exaggerating a calm and
regular rhythm:
– Take it easy.
– Just keep calm.
– Try not to panic.
– It’s OK. Don’t worry.
■ Encourage learners to practise the phrases
themselves.

173
 Nu Module 2 Planning patient care
PAGE 2:26
How to keep a
patient calm and
reassured
Task 7
Introduction and curriculum references
to use different strategies to reassure a patient,
including appropriate body language
to understand the concerns expressed by the
patient and be able to sympathise and respond
appropriately
to recognise the degree of formality by listening
to a speaker’s use of register and be able to
respond appropriately.
ESOL
Sd/L2.5a; Sd/L2.2d; Lr/L1.2b
Notes
■ Task 7 is designed to bring together the skills
for the theme. For the task you will need
photocopies of the information about the
patient’s medical setback for role A, and the
feedback form for role C. Set up the task for
groups of three, with one learner giving
feedback on the role-play.
■ For question 1, learners read through the
patient information and assess likely risks for a
medical setback, e.g. a haemorrhage from the
incision, and discuss priorities for care for each
risk they identify and the nursing actions that
would stabilise the patient’s condition.
■ For question 2, allow time for learners to
prepare their roles. With an imaginative group,
set up a mock hospital treatment area for the
role-play.
■ In question 3, learners act out the
conversation. If possible, record the role-play
and use it for evaluation and feedback.
174
■ In question 4, the nurse reports the incident to
a senior colleague and updates him/her on the
patient’s condition and the care that has been
implemented. The learner who took the
feedback role in question 3 can take the part of
the senior colleague. For the role of senior
colleague, encourage questioning, checking and
■
clarifying of information during the update.
Take feedback on the role-play: how learners
felt it went, what they found difficult and what
they found more challenging.
■ As follow up, encourage self-evaluation for the
theme. Ask learners to give themselves scores of
1 to 5 for each of these skills below. (1 = I’m
still not sure about this; 5 = I feel confident.)
I know how to:
– ask for help from a senior colleague
– give a clear and concise update
– use tenses appropriately when giving an
update
– reassure a distressed patient using a range of
strategies
– use a range of expressions to reassure a
patient
– make my voice sound calm and reassuring.
If the learner has difficulty
Work with the learners for question 2 to decide
on the strategies that would be appropriate for
reassuring this patient and phrases to use for
keeping the patient informed about what is
happening; giving reasons for the actions you are
taking; and keeping the patient calm and allaying
his/her fears.
Extension
For question 2, learners taking the role of the
nurse decide on the details of the patient’s
medical condition and relapse and act out the
situation accordingly.
 Nu Module 2 Planning patient care: Dealing with a deterioration in a patient’s condition Nu 2:20

Focus
When a patient’s condition unexpectedly deteriorates, you
need to be able to assess the problem quickly and plan and
implement nursing care to stabilise the patient’s condition.

Task 1
1 Listen to a nurse on a surgical ward dealing with a sudden
30 deterioration in the condition of one of her patients.
a What has happened?
b Discuss how effectively the nurse dealt with the
situation.
What could she have done differently?
What does she need to do now?

Any unexpected relapse in a patient’s medical condition will be very

distressing for the patient, so make sure you deal with the situation in a way
that inspires confidence and shows your concern about what is happening.

You’re doing really well. I’m just going to increase

That’s great. the oxygen to help you
breathe more easily.

Just take some

deep breaths.

■ Quickly assess the situation and decide whether to deal with the problem
yourself or ask for assistance.
■ When reporting an incident or asking for assistance, give a brief update on the
patient’s condition and any actions you have already taken.
■ Even when you are worried, don't show it; keep your voice calm and reassuring.
■ A major cause of stress for patients is not knowing what is going on,
so while giving treatment, keep the patient informed about what is happening.

175
 Nu Module 2 Planning patient care: Dealing with a deterioration in a patient’s condition Nu 2:21

How to ask for assistance 1

When asking for assistance:
● explain the problem in a clear and calm way
● give a brief update on the patient’s condition and nursing
actions you have already taken.

● Mrs Collins, 45 years old.

● Abdominal hysterectomy
3 days ago.
● Uneventful post-operative
recovery.
● Suddenly develops severe
breathing problems.

Task 2
1 Look at the patient information and quickly assess:
2 mins ● the priorities for dealing with the situation
● the immediate nursing actions that need to be taken

● at what stage the nurse would need to seek assistance.

2 Listen to the nurse asking a ward sister for assistance.

31 How does he explain the problem?

Mrs Collins. Could you her?

3 The nurse uses precise medical terms to describe the

patient’s symptoms. What are they?
4 The nurse then gives a brief update on the problem.
Tick the nursing actions he has already taken.
a Checked oxygen saturation levels
b Got the patient sitting up
c Started oxygen
d Checked for chest pain
e Called the doctor
f Taken the patient’s blood pressure

176 ESOlskills
Lr/L2.2d;
reference
Lr/L1.2b
 Nu Module 2 Planning patient care: Dealing with a deterioration in a patient’s condition Nu 2:22

How to ask for assistance 2

5 Listen again. What tenses does the nurse use as he
31 updates the ward sister? Complete the extract. Tip
When you are
updating someone,
speak clearly and
slowly and use short
statements like these:
● I’ve started oxygen
Yes, it to 90%.
at 4 litres per
oxygen at four minute.
● She says she hasn’t
litres per minute. She
any chest pain.
panicky about using the mask
and taking it off.

Task 3
1 Choose one of these situations and decide on your
2 mins immediate priorities for dealing with it, and at what stage
you would report the incident or ask for assistance.
Situation 1 Situation 2

Two days after an appendectomy and an Four days after a hip operation, a
uneventful post-operative recovery, the 60-year-old patient with diabetes
patient suddenly becomes pyrexial, with becomes hypoglycaemic.
a body temperature of 39°C.

2 Act out a conversation asking a senior colleague for

assistance, following this plan.

Explain the problem / your concerns.

Tip
When giving an update
you often use the
Ask for assistance.
present perfect.
● Her oxygen saturation
Give your update, explaining any actions level has dropped to
you have taken so far and relevant details 90%.
● I’ve started oxygen.
about the patient’s condition.

177 ESOL Sc/L1.3a; Lr/L1.2b

 Nu Module 2 Planning patient care: Dealing with a deterioration in a patient’s condition Nu 2:23

How to reassure and calm

a patient 1
When patients become distressed and anxious, it is
important to know how to reassure them and keep
them as calm as possible.
Task 4
1 Read these techniques
for reassuring patients.
Discuss which ones
you would use to
reassure patients and
in which situations.
How to reassure patients
When patients are distressed, try these techniques to help reassure them.
1 Tell your patients you understand how they are feeling.
2 Try telling them to stay calm.
3 When patients are distressed, physical contact can be reassuring, for example
holding a patient’s hand.
4 When you give instructions, make I’m just going to increase
sure they are clear and easy to follow. your oxygen so you can
5 A major cause of stress for patients breathe more easily.
is not knowing what is going on,
so keep them informed about
what is happening or is about That’s great.
to happen.
6 Explain what is happening and
how any medical interventions
will help the problem.
7 Encourage your patient by telling
them how well they are doing.
8 Avoid leaving patients alone until
they are calm or the immediate
problem is resolved.

2 Listen to the senior nurse helping the patient with breathing

31 problems. What does the nurse say to reassure the patient?

a I when you can't breathe.

b Try and breathe into the mask. Tip

If you have to leave
c Mrs Collins, you some more oxygen and get
your patient, make
you sitting up. you breathe more easily. sure the patient has
a call bell and
d through the mask and take some deep breaths. knows how to use it.
your time. That's it. well. Here’s the call bell,
just press it here if
e Bala here with you and call you …
the doctor.

3 Which of the reassurance techniques in question 1 did the ward

sister use? If necessary work with the transcript on page 187.

178 ESOL Lr/L1.6c;skills

Lr/L1.2d;
reference
Sd/L2.5a
 Nu Module 2 Planning patient care: Dealing with a deterioration in a patient’s condition Nu 2:24

How to reassure and calm

a patient 2
Task 5
1 In your culture, how much physical contact is appropriate when
reassuring patients who are distressed or anxious? What
differences have you noticed in the UK?
2 Discuss three situations in which nurses try to be sympathetic
and reassuring. How appropriate are the things each nurse does
and says? How else could they have reassured the patient?

A A 65-year-old widower from Colombia has just been diagnosed with colon
cancer. The consultant has just left his bedside after giving him the diagnosis.
The patient has recently come to the UK to live with his son, but speaks limited
English. His son works shifts and is not due in the hospital until late tomorrow.
The nurse says:
I’ll leave you now. I'm sure you need some
time alone, so that you can think about
what Mr Grafton’s been telling you.

The patient’s son is unhappy at the lack of concern shown to his father.

B Katie, a 40-year-old female patient has been diagnosed with ovarian cancer.
She is single but has just started a new relationship. She has a very good job
as a lawyer and has told the nurse how much she enjoys her work.
The nurse says:
Don't worry, it’s not a big operation
these days. You’ll be out in a few days
and you’ll soon be back to work.

The patient suddenly bursts into tears.

C A male nurse is taking a young Moslem woman to see her husband after a road
accident. When they arrive at the bedside she becomes very distressed and he
puts a reassuring arm around her shoulder and says:

I know all those tubes look very frightening but

they're helping your husband to breathe.

A few days later his supervisor takes him aside and says there’s been a
complaint about him from the young woman’s family.

179 ESOL Sd/L2.5a; Sd/L2.2d

 Nu Module 2 Planning patient care: Dealing with a deterioration in a patient’s condition Nu 2:25

How to sound reassuring

If you want to sound reassuring, try speaking in a calm
voice and a little slower than usual.

Task 6
1 Listen to seven pairs of statements reassuring a patient
33 who has just got out of bed for the first time after
surgery. For each pair of statements circle the one that
sounds more reassuring, 1 or 2.
statement a 1 2
statement b 1 2
statement c 1 2
statement d 1 2
statement e 1 2
statement f 1 2
statement g 1 2
2 Now practise reassuring a patient with a serious chest
infection. First listen carefully to each statement. Then Tip
34
practise saying it in a reassuring tone. If you want to make
a Just take it easy. We'll soon get you breathing again. your voice sound
b Try not to panic. You need to keep the mask on to reassuring, try lowering
boost your oxygen. the pitch of your voice
c The oxygen will help you breathe more easily. and slowing down the
pace a little.
d You're doing really well. That’s great.
e Here's the call bell, just ring if your breathing gets If possible, record
worse. yourself and then ask a
colleague to give you
f We’re going to put up a drip to give you fluids and
feedback on how
antibiotics.
reassuring you sound.
g I'm just going to listen to your chest again.

180 ESOL Sc/L2.1a;skills

Lr/L1.2b;
reference
Lr/L2.5a
 Nu Module 2 Planning patient care: Dealing with a deterioration in a patient’s condition Nu 2:26

How to keep a patient

calm and reassured
In this task you practise all the skills from the theme in a
role play.

Task 7
1 You are going to act out a conversation, handling an
unexpected deterioration in the condition of one of your
patients. Read some information about the patient.

● Admitted for resection of the jejunum, following an

acute bowel obstruction 4 days ago. Uneventful post-op
recovery to-date.
● Urinary catheter removed.
● Has started eating small amounts of solids.
● Reluctant to mobilise because of pain and fear of falling.
● Walked to bathroom twice today assisted by nurse.

2 Familiarise yourself with your role.

A: Patient B: Nurse

Your teacher will give you
information about a medical
setback you experience.
Read the information and be
prepared to call for assistance
from your nurse.
Your task is to deal with the deterioration in the
patient’s condition. You need to assess the problem
quickly and prioritise any nursing actions you need
to take to stabilise the patient's condition.
Before you begin, quickly review the reassuring
techniques on page 2:23.

Your task is to give constructive feedback on how

the nurse deals with the patient. Your teacher
will give you a feedback form to complete.

3 Act out the conversation between the nurse and the

patient.

181 ESOL Sd/L2.5a; Sd/L2.2d; Lr/L1.2b

 Nu Module 2 Planning patient care: Dealing with a deterioration in a patient’s condition Nu 2:27

Resources
Extension for Page 2:21, task 2, extension
1 Choose a definition for each of these medical terms.
2 Complete the missing adjectives for the nouns.

Noun Adjective Definition

Cyanosis
sy-a-noh-sis
Dyspnoea

hypertension hypertensive

hyperpyrexia

hypothermia hypothermic

hypotension

pyrexia pyrexial

hypoglycaemia

tachycardia

A B C
An elevated body Abnormally low blood Blue tinge that appears on the skin or tissue
temperature 30–40°C. sugar level. when oxygen supply is diminished.

D An increase in the heart rate E Blood pressure lower F A body temperature

above normal, e.g. due to fever. of over 40°C.
than normal.

G A very low body H Blood pressure higher I Difficult and laboured breathing present
temperature. than normal. when airways are obstructed.

3 Listen to the nouns and mark how many syllables you

32 hear, e.g. cyanosis has four syllables: sy-a-noh-sis.
4 Listen again and mark the syllable (part of the word) that
is stressed (said more strongly), e.g. sy-a-noh-sis.

182
 Nu Module 2 Planning patient care: Dealing with a deterioration in a patient’s condition Nu 2:28

Resources
Patient information for Page 2:26, task 7

A: Patient
You have just rung the call bell because you have
discovered that blood is oozing from your wound.
There is blood on your night clothes and on the sheets.
Decide how you are going to react to the situation, e.g.
● agitated and upset
● angry and upset.

Feedback form for task 7, question 2

FEEDBACK FORM

1 How appropriate were the nursing actions? Would you have

done anything differently?

2 How successful was the nurse in reassuring the patient and

keeping him / her calm?

3 Tick any of the reassuring techniques he / she used:

Telling the patient you understand how he / she is feeling.
Telling the patient to stay calm.
Giving clear simple instructions.
Telling the patient what is happening or going to happen.
Explaining what is happening.
Using physical reassurance, e.g. holding hand.
Encouraging the patient by telling him / her how well
he / she is doing.

Other techniques

4 Did his / her tone of voice sound reassuring?

Speed of delivery: too fast / too slow / about right
Pitch: too high / too low / about right

183
 Check it
Writing care plans
1 Look at these goals from care plans. Write the correct preposition or write 0
if no preposition is needed.
a Alicia will be able to dress herself without assistance ....................... discharge.
b For Alicia to perform knee exercises for 5 minutes ....................... going to bed and .......................
breakfast each day.
c For Mr Mahoro to walk independently to the end of the hall 3 times a day ....................... 10 days
of surgery.
d Mr Mahoro will be able to administer his own insulin ....................... 12 November.
e To attend the diabetics class on insulin administration ....................... 4/11/04.

2 Read this extract from a care plan. Then circle the best word (A B or C) to
complete each gap.

Date Nurse’s signature

28/01/--
Problem:
Mr Lee has shortness of breath (1)............................... acute asthma.

Goal:
to relieve (2)............................... and prevent complications.

Care planned:

Monitor respiratory rate, observe (3)............................... signs of

cyanosis and respiratory stress.
Monitor SaOz (4)............................... and (5)............................... Dr Martin if
below 90%.
Give nebulisers as prescribed and (6)............................... pre and post
peak flows.

1 A due to B because C as a result

2 A breathing B breathless C breathlessness
3 A of B for C from
4 A each 4 hours B 4 hourly C 4 hours
5 A report B refer to C inform
6 A record B write C observe

184
 3 Replace the underlined words with a more formal equivalent from the list.

administer assist ensure inform perform liaise observe record

a Help Mr Hoxta to do breathing exercises with a pillow and hand over the incision.
b Monitor and write down when Mr Bell passes urine.
c Give prescribed analgesics and tell Dr Lim if no effect within 6 hours.
d Make sure back and hips are looked at for signs of decreased circulation from
pressure points every two hours.
e Get in touch with the physio to arrange an exercise programme for Mr Bell.

Discussing care
4 Which phrase would you use to suggest an idea for the care of a patient?
a You really need to arrange for her to see a speech therapist.
b I think you should get her to see the speech therapist.
c You could speak to the speech therapist and see what she thinks.

5 Which phrase would you use to reject your supervisor’s advice politely?
‘You should get her to watch TV with the other patients in the evening.’
a I know she won’t agree to that.
b I’m not sure she’d be happy about that. She says she prefers to read.
c I suppose I could try that, but I don’t think she’ll agree.

6 Complete the missing phrases from a discussion between a nurse and her supervisor.
The first letter is given.
a If you’ve got a minute, I’d a……………………….. some feedback on my plan for Mrs Collins.
b Good idea. I’ll a…………………. that to the plan.
c I don’t think that would w……………….… She’s not keen on sweet things.
d If she’s complaining about the noise, t………………. moving her bed to the other end of the ward.
e Thank you for your help. I’m really very g………………..

Dealing with a deterioration in a patient’s condition

7 Complete these sentences for reassuring patients. Put the verbs in brackets in the
correct tense.
a You ………………………………….. (get) a lot of pain because your lungs are so inflamed.
b We ……………………………………. (give) you something to control the pain.
c The painkillers ………………………… (help) you feel more comfortable.
d I ……………………………………… (give) you an injection to stop the nausea.
e Try not to move too much. That’s it. You ………………………… (do) really well.
f I just need to get a clean dressing. I ………………………… (be) back in a minute.

185
 Nu Module 2 Planning patient care
Audio
PAGE 2:13
How to follow feedback
Task 2 23
Malika is working on the care plan for a patient in
her care and wants some feedback from her
supervisor on the ward.
Malika: I’m writing this care plan, do you think you
could have a look at it and see what you think?
Supervisor: Who’s the patient?
Malika: Mr Dubrika, bay 4. He came in yesterday
morning after a series of falls.
Supervisor: Ah, yes. I haven’t seen him yet.
Malika: Well actually, I’m a bit worried about him.
He’s hardly eaten anything since he came in, just
a spoonful of cornflakes, and a bit of toast this
morning. Nothing much else. His daughter says
he doesn’t like the hospital food.
Supervisor: OK. Could I have a quick look at his
nutritional assessment?
Malika: Nutritional assessment. Oh, I haven’t done
one.
Supervisor: Right. Well, you really should get one
done as soon as you can. With an older patient
like Mr Dubrika, it’s always a good idea to do a
nutritional assessment while you’re doing the
initial interview.
Malika: Sorry, I just didn’t think of it. I’ll do it when
we finish.
Supervisor: Fine. So, now let’s have a look at your
plan and see what you’ve got.
Malika: OK.
Supervisor: Discuss food preferences, monitor food
intake, maintain food intake chart. OK. Those
seem fine. Right, erm … Have you thought of
getting some input from the dietician? She could
work out some individual meal plans he might
find a bit more appetising.
Malika: Good idea. Is that Fiona O’Grady?
Supervisor: That’s right.
Malika: OK. I’ll add that to the plan.
Supervisor: There is one other thing. If he’s not
eating, what about a nutritional supplement? That
might be a good way to get some extra calories
into him.
Malika: Do you mean a supplement like Polycal?
186
Supervisor: No, actually I was thinking of a
nutritional drink. There’s a good one called
Fortisip. They do a sort of Ribena flavour and
various kinds of juices. They’re packed with
calories and patients really seem to like them.
Malika: So it’s good as a snack?
Supervisor: Yes, but you can also give it as a drink
with meals.
Malika: OK. I’ll think about that. What was the name
again?
Supervisor: Fortisip, but there are other ones too.
When you speak to the dietician, you could see
what she recommends.
Malika: OK. I’ll see if I can get hold of her before I
finish my shift. Is there anything else?
Supervisor: Let’s have a look. … No, the rest looks
fine.
Malika: OK. I’ll go and do Mr Dubrika’s nutritional
assessment straightaway.
Supervisor: Good.
Malika: Thanks for the help. I’m really grateful.
PAGE 2:14
How to respond to feedback
Task 3.3
Extract 1 24
Supervisor 1: I know Mr Fasad’s very happy to
interpret for his mother, but I don’t feel
comfortable about it really. He’s quite a strong
character and we need to be sure we’re doing
what she wants and not just what he wants. So, I
really think you ought to bring in an interpreter
when you’re discussing treatments with her.
Extract 2 25
Supervisor 1: If Mrs Kent’s still complaining about a
dry mouth, why don’t you offer her some sweets
to suck, or maybe bits of pineapple? That can be
very refreshing when you’ve got a dry mouth.
Extract 3 26
Supervisor 2: The exercise programme for Mr Lee
looks fine, but it might be an idea to get his
daughter to come to one of the physio sessions.
He’s going to be staying with her for a few days
when he first gets out of hospital, so it would be
really useful if she could help him with his exercises.
 Nu Module 2 Planning patient care
Extract 4 27
Nurse: Mrs Jahali is still very anxious about her
husband. She doesn’t think he’s coping at all well.
She says he’s not eating properly and seems very
depressed. What would you suggest?
Supervisor 2: Well, in cases like this, it’s always best
to get social services to talk to them. They’ll know
what support systems can be set up for Mr Jahali.
I think you need to do it straightaway. If she’s
worrying about her husband all the time, it’s
going to slow her recovery down. And we don’t
want that.
PAGE 2:15
Task 4 Extension 28
a OK. I’ll give it a try.
b I’m not sure if it’d work.
c That’s a good idea.
d I could try that, but I don’t think she’ll be
happy about it.
e I don’t think she’ll agree to that.
f OK. I’ll add it to the plan.
g Right. I’ll follow that up.
h I suppose I could do that.
PAGE 2:16
Task 5 Extension 29
An extract from Track 23.
Supervisor: Fine. So, now let’s have a look at your
plan and see what you’ve got.
Malika: OK.
Supervisor: Discuss food preferences, monitor food
intake, maintain food intake chart. OK. Those
seem fine. Right, erm … Have you thought of
getting some input from the dietician? She could
work out some individual meal plans he might
find a bit more appetising.
Malika: Good idea. Is that Fiona O’Grady?
Supervisor: That’s right.
Malika: OK. I’ll add that to the plan.
Supervisor: There is one other thing. If he’s not
eating, what about a nutritional supplement? That
might be a good way to get some extra calories
into him.
Malika: Do you mean a supplement like Polycal?
Supervisor: No, actually I was thinking of a
nutritional drink. There’s a good one called
Fortisip. They do a sort of Ribena flavour and
various kinds of juices. They’re packed with
calories and patients really seem to like them.
187
Malika: So it’s good as a snack?
Supervisor: Yes, but you can also give it as a drink
with meals.
Malika: OK. I’ll think about that. What was the
name again?
Supervisor: Fortisip, but there are other ones too.
When you speak to the dietician, you could see
what she recommends.
PAGE 2:20
Focus
Task 1 30
A patient who has recently had an abdominal
hysterectomy develops a bleed from the incision and
calls one of the nurses.
Patient: I think I’m bleeding. I felt something warm
and sticky and then when I put my hand under
the bedclothes. It’s terrible. Look, I think my
stitches’ve gone. There’s blood all down here.
Nurse: OK. Let me have a look. Oh… Yeah. You’re
bleeding from your wound. You’ve got blood all
over the sheets, and your nightdress. It’s a mess.
I’ll have to change everything. …. Don’t worry.
It’s probably not as bad as it looks. I just need to
get a few things so I can get the bleeding
stopped. Keep very still. I’ll be back in a minute.
PAGE 2:21
How to ask for assistance: 1
Task 2.2 and 2.5 31
Bala, a nurse on a surgical ward, is worried about
one of the patients, Mrs Collins, and asks a senior
colleague for assistance.
Nurse: I’m worried about Mrs Collins. Could you
come and have a look at her? She’s dyspnoeic
and she looks cyanosed.
Senior nurse: OK. I’ll come and have a look. Have
you checked her oxygen saturation?
Nurse: Yes, it’s fallen to 90%. I’ve started oxygen at
four litres per minute. She seems a bit panicky
about using the mask and keeps taking it off. Oh,
and she says she’s no chest pains.
Senior nurse: OK. Hello, Mrs Collins. Your nurse has
asked me to come and see you. I can see you’re
having a lot of difficulty in breathing.
Mrs Collins: I can’t get my breath.
Senior nurse: And you haven’t got any pain in your
chest?
 Nu Module 2 Planning patient care

Mrs Collins: No, it just feels like I’m choking.
Senior nurse: OK. I know it’s very frightening when
you can’t breathe, but you need to keep the mask
on, so we can get your oxygen levels up.
That’s it. We’ll soon have you more comfortable.
Try and relax and breathe into the mask. ... That’s
great.
Senior nurse: OK Bala. We need to get Mrs Collins
sitting up. Have you checked her blood pressure?
Nurse: Yes, it’s 130 over 70.
Senior nurse: Good. OK. We need to get Mrs
Collins sitting up. Can you get me an extra
pillow? Mrs Collins, we’re going to give you some
more oxygen and get you sitting up. It’ll help you
breathe more easily.
Nurse: Here’s the pillow.
Senior nurse: Thanks. Can you help me get her
more upright? OK. Let’s increase the oxygen to 10
litres. OK, Mrs Collins. Just breathe through the
mask and take some deep breaths. Take your time.
That’s it. You’re doing really well. OK Bala, can you
stay with Mrs Collins until she’s more comfortable
with her breathing? Bala will stay here with you
and I’m just going to call the doctor.
Mrs Collins: I still can’t get my breath.
Bala: Would it help if I held your hand, Mrs Collins?
Mrs Collins: Yes.
Task 2 Extension 32
Pronunciation of nine medical terms:
cyanosis (sy-a-noh-sis)
dyspnoea (dys-pn-ea)
hypertension (hy-per-ten-shon)
hyperpyrexia (hy-per-py-reks-ia)
hypothermia (hy-poh-ther-mia)
hypotension (hy-poh-ten-shon)
pyrexia (py-reks-ia)
hypoglycaemia (hy-poh-gly-see-mia)
tachycardia (tach-i-kar-dia)
c 1 Try not to worry. I’ll stay with you until you feel
less dizzy.
2 Try not to worry. I’ll stay with you until you feel
less dizzy.
d 1 Just lie quietly until you’re ready to sit up.
2 Just lie quietly until you’re ready to sit up.
e 1 I know it hurts when you move, so take your
time.
2 I know it hurts when you move, so take your
time.
f 1 That’s great. You’re doing really well.
2 That’s great. You’re doing really well.
g 1 Here’s the bell. Just press here if you feel sick
again.
2 Here’s the bell. Just press here if you feel sick
again.
Task 6.2 34
A nurse reassures and calms a patient who has
become feverish, and is in pain and having trouble
breathing.
a Just take it easy. We’ll soon get you breathing
again.
b Try not to panic. You need to keep the mask on
to boost your oxygen.
c The oxygen will help you breathe more easily.
d You’re doing really well. That’s great.
e Here’s the call bell, just ring if your breathing gets
worse.
f We’re going to put up a drip to give you fluids
and antibiotics.
g I’m just going to listen to your chest again.

PAGE 2:25
How to sound reassuring
Task 6 33
A nurse reassures a patient who has just had surgery
and is trying to sit up for the first time.
a 1 It’s quite usual to feel sick after an anaesthetic.
2 It’s quite usual to feel sick after an anaesthetic.
b 1 I’m just going to give you an injection for the
nausea.
2 I’m just going to give you an injection for the
nausea.

188