PIE Note 1 - Lecture notes 1 PDF

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P

I

E Name : William Tracy

Problem The problem category is like the identification the problem or nursing diagnosis from the assessment data. Both subjective and objective data are utilized to determine client’s current and potential problem

Intervention The intervention category reflects the implementation phase of the nursing process and includes immediate nursing actions.

Evaluation The response category reflects the evaluation phase of the nursing process and describes the client’s response to any nursing and medical care.

Section: 108-006

Possible PTSD Sara Kathryn Horton was admitted to the hospital with 2 gun shot wounds. She was a victim of a school shooting. Patient found out her best friend had died at the scene of the shooting. Patient was heard screaming in her sleep. Patient was seen jump out of wheelchair and hit the ground when she heard a jackhammer on her way outside of the hospital. Patient stated she was scared to the leave the hospital due to the school shooting. Find coping mechanisms that work for the patient. Referral to Psychology. Provide puzzles, books, a phone for distraction from pain and her psychological stress. We need to be mindful of this patient and keep loud noises to a minimum. Do your best to not crash anything or make loud noises nearby. Provide a therapist if wanted Provide a visit to the chapel if wanted The scenario mentioned the use of a coping mechanism to deal with stress. There was no information on the psychology referral. Patient was released from the hospital with help from family members. I would highly recommend the use of a therapist when the family is leaving.

Date: 11/6/2020

Instruction: Using one of your assigned patients from Swift Rivers, Create a PIE Note. Problem #: Possible PTSD with Sara Kathryn Horton (School shooting victim)...