Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬

Ministry of Education ‫وزارة التعليم‬

University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
Student Name ALBANDARI HUDIBAN
Student ID 20200593
Date 16/02/2021
Hospital KSSH

Instructor Name DR. Dolores cabansag

Patients Data
Patient’s name (First & surname): Mrs. : S. A
1003601
Healthcare Record Number (HRN):

Age: 32 Y.O

Gender: female
Presenting Chief complaint: sever abdomen Pain & vomting
Triage category: 3 urgent

Infection status: Acute

Accompanied by: family

Patient
Family or significant other
Source of data collection/gathering Caregiver
EMS personnel
Bystander
Use of translator
Medical Diagnosis: Appendicitis

Last oral intake: Paracetamol 500mg

Mechanism of injury (if any)

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 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
Blast Forces (Explosions)
Blunt Forces
A. motor vehicle collisions,
B. automobile versus pedestrian collisions
C. motorcycle collisions,
Types of Injuries (if any)
D. sports-related activities,
E. falls
Penetrating Forces
A. Stab wounds
B. Gunshot wounds
Mechanical energy
Type of Energy caused Thermal energy
Injury/Trauma Electrical energy
Chemical energy
Effected Organ of the
No
Injury/Trauma
Trauma Score (Refer to Revised
0%
Trauma Score Appendix)

Summary of the Primary Assessment:

List all abnormalities based on primary assessment (refer to Primary Assessment Guidelines)
Under observation, She was a pyrexial with stable vital signs. The abdominal examination revealed a soft
abdomen, tenderness on percussion, rebound tenderness in the RIF
Vital signs =
• BP 120/75, P 83 and regular
• BP 118/70, P 80 and regular
• RR 14 and unlabored
• T 37 C orally
• SaO2􏰁97%
Wt= 46 kg

History of Present Illness/injury/chief complaint

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 Kingdom of Saudi Arabia ‫المملكة العربية السعودية‬
Ministry of Education ‫وزارة التعليم‬
University of Hail ‫جامـعـة حـائل‬
College of Nursing ‫كلية التمريض‬

Emergency Nursing Care I Practical (NURS 516)

Patient Assessment & Nursing Care Plan (10%)
(Repeat this table for each of the symptoms)
The pain was exacerbated by lifting the right leg and relieved by leaning
Palliative Factors forwards.

sharp and colicky in nature with progressing intensity.

Provocative Factors
nausea & vomiting
Quality
Abdomen
Region
right lower quadrant)RLQ(
Radiation
Severity was rated 10on a scale of one to 10
Severity

Timing: Onset sever diffuse abdominal pain since six -hour

6h
Timing: Duration
1-3 min
Timing: Frequency
Under observation, She was a pyrexial with stable vital signs. The abdominal
Treatment prior to
examination revealed
arrival
a soft abdomen, tenderness on percussion, rebound tenderness in the RLQ

Pathophysiology of the Disease/ Patient condition/ Medical Diagnosis

Appendicitis is a condition defined as the inflammation of the inner lining of the vermiform appendix which
also spreads to its other parts. It is a common and urgent surgical condition with protean manifestations,
generous overlap with other clinical syndromes, and significant morbidity, which increases with
diagnostic delay. Despite diagnostic and therapeutic advancement in medicine, appendicitis remains a
clinical emergency and is one of the more common causes of acute abdominal pain. Acute appendicitis is
the most common condition leading to surgery for patients with abdominal pain. 
Distention of the appendix initially leads to poorly localized epigastric or peri-umbilical visceral pain,
which may be accompanied by anorexia, nausea, or vomiting. With peritoneal involvement, the pain
becomes localized to the right lower quadrant, often at Mc Burney point (5 cm from the anterior superior
iliac spine on a line running to the umbilicus).

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 Full Set of Vital Signs
Pain
Blood Pressure Temperature Central & Peripheral Pulse SpO2 GCS
Severity
Time
Locatio
Location Value MAP Route Value Rate Rhythm Quality
n
8:00 RT arm 138/90 103 Oral 36.8 Apical 90 Regular strong 91,% 15 10
9:00 RT arm 139/89 104 Oral 35 Apical 93 Regular strong 95% 15 9

10:00 RT arm 132/84 100 Oral 36 Apical 92 Regular strong 99% 15 9

11:00 RT arm 131/79 96 Oral 35 Apical 89 regular strong 89% 8 0

12:00 RT arm 130/78 95 Oral 37 Apical 88 Regular strong 99% 3 0
1:00 RT arm 130/78 95 Oral 36 Apical 100 Regular weak 99% 3 0
2:00 RT arm 129/77 94 Oral 34 Apical 105 regular weak 98% 15 0
3:00 RT arm 125/75 89 Oral 36 Apical 100 Regular weak 97% 15 0
4:00 RT arm 127/72 92 Oral 36 Apical 90 Regular strong 99% 15 0

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Diagnostic Examinations/Procedures:
(Include Blood type, Lactate, ABGS, ECG, CTCO2, Lab Tests, radiographic studies, etc…)
Preference
Value Patient
Test/Procedure Nursing Considerations
(Normal Results
Results)
Pre-test
 Explain procedure
 Check Vital Signs every
2 hours and check for patient’s
skin
During Test
 Provide Privacy
 Determine if the test is
Blood count accurately performed according
to the procedure
 Record the result
Post Test
 Monitor patient
response
 Document

Abdominal Ultrasound

Urine analysis

5
 Pain Assessment
Palliative Factors
The pain was exacerbated by lifting the right leg and relieved by leaning forwards.
Provocative Factors
sharp and colicky in nature with progressing intensity.
Quality
nausea & vomiting
Region
Abdomen
Radiation
right lower quadrant)RLQ(
Severity*
Severity was rated 10on a scale of one to 10
Timing: Onset
sever diffuse abdominal pain since six -hour
Timing: Duration
6h
Timing: Frequency
1-3 min
* Pain Scale used for severity assessment:
FACES pain rating scale for patients approximately 3 years of age and older
Visual analog scale for school-age children and adolescents

6
 FLACC (Faces, Legs, Arms, Cry, Consolability) Scale for infants and preverbal
children
Numeric rating scale for older school-age children and adolescents

Past Medical History

Patient’s definition of own health

Self-rated

past medical history (PMH), to include hospitalization/ surgeries:

The patient received all vaccinations and took the flu vaccination a month ago. She has
no previous medical history. They are young and in good health. Just a year ago, she had
a slight fever, she took antibiotics, and she got better, and she had never had operations,
hadn't been hospitalized, and had no allergy.

Current or preexisting diseases/illness/injuries/surgeries

Respiratory disease
Neurologic disease
Endocrine disease
Hepatic disease
Infectious disease
Hematologic disease
Immunosuppression
Autoimmune disease
psychiatric or mental health
Others, Specify:

Allergies
Medication—prescription, OTC
Food/beverages
Latx
Iodine
Environmental

Immunization status

Pneumococci
Influenza
Tetanus
Childhood illnesses

Psychological/social/environmental factors

Smoking:

7
No

Substance and/or alcohol use/abuse:

No

Safety
Possible/actual assault, abuse, or intimate partner violence
situations
Use of seat belts
Texting while driving
Drinking and driving

Psychiatric history (personal or family members):

Her grandfather is 77 years old and has DM
Her grandmother died at the age of 70 due to HTN
Father 55 years old has HTN and DM
The mother is 40 years old and does not have a history of illness
Her sisters, aged 33 and 25, have no history of illnesses.

Literacy (level of Education)

High Bs

Behavior appropriate for age and developmental stage:

normal

Occupation/profession:
normal

Meaning of illness, injury, or event to patient/family:

significant

Patient’s/family’s expectations of care:

good

Support system:
Family structure
Significant others
Social agencies
Religious affiliation
Caregivers

Responsibilities

Self
Family
Business

8
 Community

Cultural beliefs and practices:

Exeresices

Spirituality:

Living accommodations
House
Apartment
Accessibility (e.g., stairs)
Homeless, shelters

Affordability and accessibility to care—socioeconomic status:

normal
History of descriptive and non-descriptive medications:

Descriptive medications (Prescribed by physician/doctor):

Generic Name & /

Classification
Trade Name
Dosage
Frequency
Route

None

9
 Non-descriptive  medications: Legal/ illegal, over the counter drugs (OTC):

Generic Name & /Classification

Trade Name
Frequency
Route
Rationale

paracetamol
Panadol
BID
By oral
headache

Head-to-Toe Assessment (Review of Systems)

Describe only abnormal findings: Refer to Chapter one (Nursing Assessment and Resuscitation)
General appearance
General survey:
.Patient is a well-developed, well-nourished, pleasant, talkative, cooperative, and slightly anxious
Alert and oriented to person, place, and time •
• She is well dressed in a suit, well groomed, and appears younger than her stated age.
the patient being examined in a sitting position; the following systems are reviewed
Skin/mucous membranes/nail beds
 Skin. The exposed areas of the skin are observed; the size and shape of any lesions are noted.

Head and face

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 Head. The hair, scalp, skull, and face are examined

Eyes/ Ear/ Nose/ Mouth/ Neck

 Eyes. The external structures are observed. The internal structures can be observed using an
ophthalmoscope (a lighted instrument) in a darkened room.
 Ears. The external structures are inspected. A lighted instrument called an otoscope may be used to
inspect internal structures.
 Nose and sinuses. The external nose is examined. The nasal mucosa and internal structures can be
observed with the use of a penlight and a nasal speculum.
 Mouth and pharynx. The lips, gums, teeth, roof of the mouth, tongue, and pharynx are inspected.
 Neck. The lymph nodes on both sides of the neck and the thyroid gland are palpated.

Chest
All normal

Abdomen/flanks
The patient being examined should lie flat for an examination of the:

 Abdomen. Light and deep palpation is used on the abdomen to feel the outlines of internal organs,
including the liver, spleen, kidneys, and aorta, a large blood vessel.
 Rectum and anus. With the person lying on the left side, the outside areas are observed. An internal
digital examination (using a gloved finger), is usually done for persons over 40 years old. In men,
the prostate gland is also palpated.

Pelvis/perineum
 Reproductive organs. The external sex organs are inspected and the area is examined for hernias. In
men, the scrotum and testicles are palpated. In women, a pelvic examination is completed using a
speculum and a sample for a Papanicolaou test (Pap test) may be taken.

Extremities
 Legs. While lying flat, the legs are inspected for swelling, and pulses in the knee, thigh, and foot
area are found. The groin area is palpated for the presence of lymph nodes. The joints and muscles
are observed.
 Musculoskeletal system. With the person standing, the straightness of the spine and the alignment of
the legs and feet is noted.
 Blood vessels. The presence of any abnormally enlarged veins (varicose), usually in the legs, is
noted

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 Currently Described Medications
Generic Name Trade Name/
Adverse Reactions Nursing Responsibilities
(Dosage, Route, Frequency) Classification
Monitor patient response to
therapy (decrease in signs and
symptoms of infection).
Monitor for adverse effects
(e.g. orientation and affect,
hearing changes,bone marrow
Diarrhea suppression, renal toxicity,
Zinacef Cefuroxime Na
Dizziness hepatic dysfunction, etc).
750mg/IV/3times Group
Nausea Evaluate patient understanding
on drug therapy by asking
patient to name the drug, its
indication, and adverse effects
to watch for.
Monitor patient compliance to
drug therapy.
Vomiting
Flagyl
Metronidazole Diarrhea
500mg/IV/3Times
Metallic taste
Pethidine Pethidine HCL Respiratory Monitor patient response to
3CC/IM/PRN depression therapy (relief of acute
Hypotension migraine headache).
Confusion Monitor for adverse effects
(e.g. CV changes, arrhythmias,
hypertension, etc).
Evaluate patient understanding
on drug therapy by asking
patient to name the drug, its

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 indication, and adverse effects
to watch for.
Monitor patient compliance to
drug therapy.

Treatments/Therapeutic Regimens/Doctor Orders rather than Medications

(e.g. oxygenation, ventilation, intubation, cardioversion, IV therapy, etc.)
Establish IV access for administration of crystalloid fluids/medications

Allow patient position of comfort.

Prepare for/assist with medical interventions

Initiate and maintain NPO status

Administer pharmacologic therapy as ordered
Nonnarcotic analgesics/ Narcotics/ Antibiotics/ Antipyretics.

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 NURSING CARE PLAN
(Provide 3 Nursing Diagnosis and write one Nursing Diagnosis per Page)

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 References
1. Brunner and Suddarth’s Textbook of Medical Surgical Nursing. Eleventh
Edition.
2. Priscilla lemone medical surgical nursing .
3. Ross and Wilson Anatomy and Physiology in Health and Illness,Tenth Edition.
4. http://www.gastro.org/wmspage. American Gasteroenterogical Association
5. Medical Surgical Nursing Critical Thinking in client care Third Edition

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