OSCE – Care plans

Subdural hematoma

Nursing problem 1: John is experiencing a headache due to subdural haematoma.

Aims of care: John will state that his pain is manageable and will have a pain score of 3 or less out of 10.
Re-evaluation date: John’s pain will be evaluated 20-30minutes pre and post administration of analgesia
and his care plan reviewed every shift starting today date.00/00/2018 or if clinical condition changes.

Care by Nurses Self-care

 Explain and discuss all aspects of care with John  John verbalises understanding of his plan of
and gain consent for all procedures care
 John’s current GCS is 14 therefore his GCS and  John verbalises understanding of the pain
observations should be monitored and assessment tool and demonstrates ability to
documented half hourly score his pain from 0-10.
 Assess John for verbal and non-verbal signs of  John demonstrates use of the call bell when
pain using the pain assessment tool and requiring analgesia
recording score between 0-10.  John understands the education he has been
 Administer analgesics as prescribed and record given
on medication administration chart  John will actively participate in his care plan
 Reassess John’s pain 30 minutes post
administration of analgesia to monitor effect of
treatment
 If pain relief is ineffective, escalate to nurse in
charge, treating doctor and pain team (if
appropriate) using SBAR
 Inform and reassure John of his plan of care
 Document all care given
Nursing problem 2: John is at risk of falling due to mild confusion caused by his subdural hematoma and
history of falls

Aims of care: For John to be able to mobilise safely and independently with no falls during hospital stay. For
GCS to be 15.

Re-evaluation date: John’s Falls risk assessment to be completed on admission or within 6 hours of
admission. GCS will be evaluated hourly and his care plan should be reviewed each shift starting today
00/00/2018.

Care by Nurses Self-care

 Explain and discuss all aspects of John’s care and  John verbalises understanding of his plan of
gain consent for all procedures. care
 Complete a falls risk assessment of John on  John demonstrates use of call bell when
admission, continue assessing during hourly wanting to mobilise
rounding and consider the need for 1:1 nursing  John verbalises his understanding of
care mobilising only with supervision/assistance
 Ensure John has appropriate footwear on when  John will actively participate in his care plan
mobilising  John verbalises understanding of the
 Educate John regarding use of the call bell to education given.
alert nursing staff he would like to mobilise and
ensure call bell is always within reach.
 Refer to physiotherapist to assess mobility
 Educate John and his family on falls prevention
strategies
 Refer to OT for home assessment prior to
discharge if needed
 Reassure John and family of aspects of his care
 Document all care and education given

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Post-operative patient

Nursing problem 1: Jane is experiencing post-operative pain due to abdominal surgery

Aims of care: For Jane to state her pain is manageable and her pain score to be 3 or less out of 10 (decrease
pain from 9/10 to 3 or less out of 10 in 24 hours)
Re-evaluation date: Jane’s pain will be assessed during observations every 15 minutes for first hour, every
30minutes for the second hour, hourly for four hours and pre and post administration of analgesia and her
care plan updated every shift or if clinical condition changes.
Care by Nurses Self-care
 Explain and discuss all aspects of her care and  Jane verbalises understanding of her plan of care
gain consent for all interventions  Jane verbalises understanding the pain
 Monitor and document Jane’s vital signs on the assessment tool and demonstrates ability to use
NEWS chart as per post operative guidelines i.e. the tool and score pain between 0-10.
every fifteen minutes for the first hour, half  Jane demonstrates ability to use the call bell
hourly for the second hour and hourly for the when requiring analgesia
next four hours.  Jane will actively participate in her plan of care
 Assess and record Jane’s pain using the pain
assessment tool when taking observations and
pre and 30 minutes post administration of
analgesia to monitor effect
 Administer analgesia as prescribed and
document on medication administration chart
 If analgesia ineffective, escalate to nurse in
charge and treating doctor/s using SBAR.
Consider referral to the pain team if required.
 Reassure and educate Jane about her plan of care
 Document all care and education
Nursing problem 2: Jane is at risk of developing a post-operative infection at her wound site
Aims of care: To prevent Jane from developing a post-operative infection as evidenced by Jane stating that
there is no redness, heat, swelling or excess pain from wound and no fevers noted post operatively.
Re-evaluation date: Jane's surgical site to be assessed on arrival to the ward for any signs of bleeding,
continue assessing incision site area each shift. Vital signs to be assessed as per post operative protocol
or if clinical condition changes.
Care by Nurses Self-care
 Explain and discuss all aspects of Jane’s care  Jane verbalises her understanding of her
and gain consent for all interventions plan of care
 Jane’s wound site should be assessed each  Jane demonstrates use of call bell and
shift for signs of infection including redness, understands to notify nurses if she feels
pain, odour and ooze. feverish or requires analgesia
 Change Jane’s wound dressing as per post-  Jane understands importance of wound
operative instructions (or as required if dressing protection while healing e.g.
dressing becomes soiled) using aseptic non notifies nurse prior to showering to allow for
touch technique and document wound wound to be appropriately covered.
appearance, dressing used and method of  Jane demonstrates her understanding of the
cleaning the wound. education given
 Monitor and document Jane’s observations  Jane will actively participate in her care plan
as per post-operative policy i.e. every fifteen
minutes for the first hour, half hourly for the
second hour and hourly for the next four
hours. If Jane develops a fever, immediately
contact nurse in charge and treating team.
 Administer all medications as prescribed
(including analgesia and antibiotics) and
document on the medication administration
chart.
 Educate and reassure Jane about wound
infection prevention strategies
 Document all cares given

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Nursing problem 3: Jane is experiencing post-operative nausea and vomiting (or Janes is at risk of developing a
fluid and electrolyte deficit due to post operative nausea and vomiting)
Aims of care: Jane will report a decrease in nausea within in 6 hours. The patient will be able to tolerate oral
intake within 12 hours without any nausea or vomiting.
Re-evaluation date: To evaluate Janes's nausea 20-30minutes pre and post anti emetics. Vital signs to be
assessed as per post operative protocol or if clinical condition changes.
Care by Nurses Self-care
 Explain and discuss all aspects of Jane’s care  Jane verbalises her understanding of her
and gain consent for all interventions plan of care
 Monitor and document Jane’s vital signs on  Jane demonstrates use of call bell
the NEWS chart as per post operative  Jane demonstrates understanding of the
guidelines i.e. every fifteen minutes for the importance of notifying nurses when feeling
first hour, half hourly for the second hour nauseas and will tell them of all fluid
and hourly for the next four hours. input/output.
 As part of post operative observations, Jane  Jane will actively participate in her care plan
should be monitored for signs of dehydration
e.g increased HR, decreased BP, dry mucous
membranes,
 Ensure call bell and emesis bag are within
reach for patient to reduce patient’s anxiety
 Position Jane in a comfortable and relaxed
position
 Jane’s nausea should be assessed
 Administer anti-emetics as prescribed and
document on medication chart
 Monitor and record all fluid input and output
on a fluid balance chart. Educate Jane about
the fluid balance chart and the importance
of her notifying nurses of episodes of emesis,
urination, etc.
 If Jane’s episodes of nausea and vomiting
continue, assess for signs of dehydration
including dry mucous membranes, skin
tugour, low urine output (and concentrated
urine), increased HR, etc and notify nurse in
charge and treating doctor. Consider need
for IV fluids to replace lost fluids.
 Provide distraction techniques
 Document all cares given
Chest Infection

Nursing problem 1: John is experiencing shortness of breath due to chest pain as exacerbated by his COPD.
Aims of care: For John’s to state he is able to breathe comfortably and without difficulty. For John’s work of
breathing to decrease as evidenced by a respiratory rate of 12-20 rpm and for him to be able to maintain his
baseline oxygen saturation target (88-92%) on room air.
Re-evaluation date: John’s observations and respiratory effort should be assessed every 4 hours while his
NEWS score is 2. His care plan should be evaluated every shift or if clinical condition changes.
Care by Nurses Self-care
 Explain and discuss all aspects of John’s care  John verbalises understanding of his plan of
with him and gain consent for all care
interventions  John demonstrates use of call bell and
 Johns NEWS score is 2 therefore his verbalises that he will notify nurses if his
observations should be monitored and shortness of breath worsens
documented 4-6 hourly (unless condition  John is able to provide adequate sputum
changes) particularly his respiratory rate, sample to be sent for testing
oxygen saturation and temperature to assess  John will actively participate in all aspects of
progression of his condition. care
 Ausculate John’s lungs to assess air entry  John demonstrates understanding of
 Ensure John is positioned comfortably and positioning to allow greater air entry by

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 sitting up in bed for maximum lung positioning himself appropriately.
expansion and educate him regarding this
 Administer medications (including oxygen) as
prescribed and document on medication
administration chart. Oxygen administration
to be weaned if John meets the oxygen
saturation criteria.
 Measure John’s peak expiratory flow pre and
post medication administration to evaluate
effectiveness of treatment
 Refer John to physiotherapist for assessment
 Encourage deep breathing exercises
 Educate John regarding how to give a
sputum sample
 Document all cares given
Nursing problem 2: John is experiencing activity intolerance due to low oxygenation due to chest infection and
COPD.
Aims of care: John will demonstrate a measurable increase in tolerance to activities with absence of excessive
fatigue.
Re-evaluation date: John’s observations should be assessed every 4 hours while his NEWS score is 2. His care
plan should be evaluated every shift or if clinical condition changes.
Care by Nurses Self-care
 Explain and discuss all aspects of care to  John will verbalise understanding of his care
John and gain consent for all interventions plab
 Johns NEWS score is 2. Monitor, report and  John will actively participate in his care plan
document John’s observations 4 – 6 hourly  John veralises that he understands the need
on NEWS chart as per NEWS score guidelines to increase his exercise and level of activity
including assessing John’s oxygen saturations as able to
and respirations with regards to depth,  John demonstrates how to use the call bell
rhythm and pattern. when needing assistance
 Administer John’s medications (including
oxygen) as prescribed and document on
medication administration chart. Wean
oxygen as patient able to maintain target
oxygen saturation.
 Evaluate John’s degree of deficit and assess
his ability to stand and mobilise.
 Encourage John to gradually increase his
activities and exercises, assist him in doing
passive to active and full range of movement
exercises. Provide John with adequate
periods of rest.
 Educate John on use of call bell and
encourage him to use when needing
assistance with mobilising
 Refer John to physiotherapist if needed to
assist with strategies/exercises to increase
activity tolerance as patients condition
improves
Chest pain

Nursing problem 1: Terry is experiencing chest pain with unknown aetiology

Aims of care: For Terry to state that his pain is manageable with a pain score of 3 or less out of 10.
Re-evaluation date: Due to unknown cause, Terry should be monitored hourly until cause identified or pain
ceases. Terry’s care plan should be evaluated each shift or if clinical condition changes
Care by Nurses Self-care
 Explain and discuss all aspects of care with  Terry verbalises understanding of his plan of
Terry and reassure and educate him care
regarding any anxieties he expresses. Gain  Terry verbalises understanding of pain

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 consent for all interventions assessment tool and demonstrates ability to
 Terry’s NEWS score is 0 however clinical score pain out of 10.
judgement maintains that as Terry is  Terry demonstrates use of call bell and
experiencing chest pain with an unknown verbalises understanding to notify nursing
cause, his observations should be monitored staff if pain worsens or if he is concerned
and recorded until cause of chest pain is  Terry will actively participate in care plan
found or pain ceases.
 Assess Terry’s pain using verbal and non
verbal signs using the pain assessment tool,
As part of the pain assessment, ask Terry
pain’s location, whether it radiate and where
to, a description of the pain, what factors
make it better or worse (if any) and ask Terry
to score pain severity between 0-10.
 Position patient in position that promotes
comfort and ensure he is well supported by
pillows
 Administer analgesia as prescribed and
document on medication administration
chart
 Reassess Terry’s pain pre and 30 minutes
post administration of analgesia to evaluate
effectiveness of treatment
 Perform an ECG on Terry to rule out cardiac
cause of chest pain and report finding to
nurse in charge and treating team. If
abnormalities detected, consult with treating
team for further inventions required e.g.
blood tests, cardiologist referral, etc.
 Document all cares given
Stroke patient

Nursing problem 1: Jimmy is at risk of aspiration due to right sided hemiparesis following a stroke
Aims of care: To reduce Jimmy’s risk of aspiration. Jimmy will demonstrate a reduced risk of aspiration.
Re-evaluation date: Jimmy's observations should be assessed every 4 hours while his NEWS score is 2. His
care plan should be evaluated every shift or if clinical condition changes.
Care by Nurses Self-care
 Explain and discuss all aspects of care and  John verbalises understanding of his plan of
gain consent for all procedures care
 Assess Jimmy using MUST (malnutrition  John verbalises that he understands the
universal screening tool) weekly or upon Malnutrition universal screening tool
change in clinical condition, action as per  John demonstrates use of the call bell when
protocol. Weigh Jimmy weekly, calculating needing assistance with oral intake
BMI and record.  John will actively participate in his care plan
 Ensure Jimmy is given assistance to choose
his meals and offer him a soft diet to ensure
all fluids a thickened with resource to an
appropriate consistency.
 Provide assistance and supervision for Jimmy
during meal times. Ensure he is appropriately
positioned upright while eating and is given
adequate time to enjoy his meals. Monitor
Jimmy’s swallowing.
 Monitor food and fluid intake and output on
a input/output chart and review intake 6
hourly? (or calculate 12 hourly? E.g. FBC)
 Refer Jimmy to occupational therapist for
assessment
Pre op patient

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Nursing problem 1: Terry is experiencing anxiety related to lack of understanding of his surgical procedure
Aims of care: Terry will verbalise that he feels less anxious (or no longer anxious) about his surgical procedure
Re-evaluation date: To evaluate vital signs as per NEWS score 4 hourly with the NEWS score of 4. To
complete pre operative checklist and pre operative observation prior sending for the surgery.
Care by Nurses Self-care
 Explain all aspects of care to John and gain  Terry and his NOK will verbalise his
consent for all procedures understanding of the care plan
 Assess Terry’s level of anxiety using verbal  Terry verbalises an understanding of the
and non-verbal signs surgical procedure and recovery
 Educate Terry about his surgical procedure  Terry demonstrates use of call bell when
and invite him to ask questions requiring assistance/has further questions
 Refer surgeon to speak to patient regarding  Terry will actively participate in care plan
procedure and what to expect post
operatively
 Ensure Terry has understood education by
asking him to explain his understanding of
the surgery
 Maintain a calm, supportive and confident
manner when interacting with Terry.

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