Nursing assistant Ella is checking on her patient Mr. Shelley today. When she asks how he is feeling, he says he is in pain. He says his back hurts more than yesterday. He asks Ella for more medication to help ease the pain. Ella tells him she isn’t sure if he can have more medication today. She will have to check his care plan first.
Every patient’s medical record contains a care plan, which is a document that includes information about what types of treatments the patient should receive. The care plan also indicates how much and how often Mr. Shelley should receive his pain medication. At Ella’s hospital, the patients’ care plans are electronic, which means that workers can access the care plans on computers and tablets.
Ella checks Mr. Shelley’s care plan on the computer. His care plan indicates that he receives a certain amount of pain medication only every four hours. Ella tells Mr. Shelley that she is sorry he is in more pain today. She says she will check with Mrs. Aldrich, the supervising nurse, to see if Mrs. Aldrich can give him a little more medication. Mrs. Aldrich will be able to determine if increasing his dose for one day is acceptable. If it is not acceptable, Ella will return to Mr. Shelley and ask him what else she can do to make him more comfortable. She will suggest they go watch TV or do a puzzle with his friends in the common room.
Ella wants to help Mr. Shelley feel better, but she knows she must always follow the instructions on his care plan and the directions of the supervising nurse.
Ella Checks Mr. Shelley's Care Plan