Trish Green Clinical Care Plan

Running head: 10191 Foundations for Professional Practice 2 1
Patricia (Trish) Green Clinical Care Plan.
(Author’s name)
(Institutional Affiliation)

10191 Foundations for Professional Practice 2 2
Introduction.
This assignment will cover Trish case study where a nursing care plan will be developed.
During the development of the nursing care plan, Trish medication chart and observations form
will be used together with ABCDE health assessments to create a clinical analysis that will be
used in formulating a clinical judgment. In addition, a person-centered assessment that is needed
for Trish during the shift will be discussed as guided by evidence-based literature. Finally,
Immediate nursing care priorities will be identified with proper nursing care plans of care and
evaluation strategies as sported by patients assessment and needs of care from the case study.
Case Overview.
Patricia (Trish) Green a 45 years old female patient is a mother of two children Lucy and
Ella aged 20 and 16 receptively. The patient is not currently married but lives with his partner
Steve. Her firstborn lives with boyfriend but the last born is currently at school at which her
father together with Trish support her equally. Trish is currently a sex worker for the past two
years of which none of her children are aware of her job. Trish past medical and surgical history
include tonsillectomy when she was 10 years old, uterine fibroid after giving birth to the second
born and a fractured ankle due to a skiing accident two years ago. Trish was admitted three days
ago due to appendicitis where she received emergency surgery two days ago with no major
postoperative complications. Since yesterday Trish has been moving around with minimal or no
assistance at which she has been doing activities of daily livings by herself. Besides, she has
been able to eat and drink moderately and slept well during the night although she has not
opened the bowels postoperatively. Trish has also normal regular oral analgesia during the day.
At 0600 hrs, her vital signs were Temperature 36.3, RR 13, HR 112, BP 114/72. The current
complaints are lower abdominal tenderness at 6/10 when assessed using a 10 point pain scale.

10191 Foundations for Professional Practice 2 3
The pain scale since admission has been ranging between 3 and 6. Major analgesia that has been
used in treatment include per oral Endone 5-10mg three times a day and paracetamol 1g 4-6
hourly. The patient has also been treated with Ondansetron 4-8 three times a day for nausea
warfarin for prophylaxis and peroral metronidazole 400mg 8 hourly.
ABCDE Clinical Data Analysis.
Airway- From the case study and observations, Trish has not demonstrated any signs of
respiratory distress. No recorded airway obstruction has been experienced meaning she has open
airway for normal breathing. Besides, Trish oxygen saturated rates have been at normal ranges
ranging from 96% to 98% at which her oxygen saturation is currently at 96%.
Breathing- Trish has a normal respiratory rate throughout the hospital stay ranging from 10 to
15 beats per minutes. Trish current RR is at 13 beats per minute. Other than that, the patient has
no mechanical blockages or injuries that inhibit mechanical breathing. However, when
examining the pattern, Trish could have been having a breathing problem especially prior and
after surgery where three of her RR have been recorded to be 11, 11 and 10 beats per minute.
According to the British Resuscitation Council, normal breathing rates are supposed to be
between 12-20 in females with Oxygen saturation rates of 94% to 100%(Resuscitation Council,
2019).
Circulation- From the case study, Trish has no symptoms of inadequate blood circulation like
pale digits, poor capillary refill, access to veins or poor hear murmurs when auscultated. Her
blood pressure has been within normal ranges, that is no recorded systolic blood pressure has
been bellow 100mmHg and diastolic blood pressure of below 90mmHg but above 50mmHg as
recommended by Australian Commission on Safety and Quality health care (ACSQHC) 2017.
Trish BP has been ranging from 110/70 to 129/70mmHg throughout the hospital stay. However,