Problem
Rayna Jones. Address = 90 Sippy Downs Drive, Sippy Downs, Queensland. 4556. Date of Birth = 01/01/1974. Patient ID = 12345678.
Rayna is an Aboriginal Torres Strait Islander person. She works at a local hardware supply store and is married. Rayna has three adult children, and five grandchildren, who live in either New South Wales or Western Australia. She lives at home with her partner, in a house that they purchased 10 years ago, after moving from Victoria. Rayna loves to go for walks with her dog, and meet friends at a local coffee shop each morning, although not lately. Her friends take turns calling or visiting each day. One of their friends who is a Registered Nurse was worried about her, and suggested that she gets a medical 'check-up'.
Rayna has developed a few medical issues over the past five or so years. She tells you that she is on medication for an irregular pulse and high blood pressure, that she is fully vaccinated and that she regularly sees a General Practitioner (GP/Dr) at Galangoor Duwalami primary health care service. Around 4 weeks ago, Rayna developed a sore throat and flu-like symptoms. Since this time, she has had a dry cough.
She tells you that she has never smoked and that she only consumes alcohol socially, but not since being unwell. Further, she has only been in hospital for grommets as a child, due to frequent ear infections. She recounted how she did not like hospitals as a child because they wouldn't let her go home to see her parents. Rayna said she still doesn't like hospitals and refuses to go, instead preferring to wait for an appointment with the GP/Dr at Galangoor Duwalami primary healthcare service. She wears glasses for reading but has noticed recently needing to use them more at work.
You observed that Rayna was limping when she was walking into the consultation room. She tells you that she has had discomfort in the lower thigh and behind the knee for the past two days.
Rayna states that she may have strained a muscle, although she does not remember a specific event for the injury. She has regularly been taking Panadol for the pain.
You measure some observations and her height and weight: temp 37.90C; respiratory rate 20 breaths per minute; Sp02 95% on room air; pulse 55 beats per minute (regular); blood pressure = 148/70 mmHg; pain score 6/10; height 168 cm and weight 95 kgs.
Task
A. Select two problems or potential problems from the case study and develop a person-centred care plan as below.
B. Select the relevant sub-standard from NMBA Registered nursing standard for practice. Discuss how you have met this sub-standard.
C. Using the progress notes page and the observation graph chart, document the persons assessment and plan of care using SOAP framework.