Assessment : Nursing care of a person in a medical surgical setting
Based on the handover you received at the beginning of your shift today, other information included below and current reliable evidence for practice, address the following 5 tasks as a registered nurse looking after him.
Do not make up or assume information in relation to or about Jim. Only use what you know from the information you received today.
Task 1: Patient assessment
Assessment is one of the major roles of the registered nurse and is the first step in the nursing process to assist in planning and to facilitate mutually established goals and evaluate outcomes. In reality the nurse is continually assessing and re-assessing the patient throughout the continuity of care.
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice
• Identify 3 specific nursing assessments that you would conduct as a priority for Jim’s nursing care that you will undertake on Jim’s admission to your ward.
AND
For each assessment you have identified explain:
• Why the assessment is relevant to Jim’s care.
• What consequences may occur if this assessment is not completed accurately?
(300 words, 10 marks)
Task 2: Care planning
Based solely on the handover you have received and using the template provided, develop a care plan for five (5) nursing problems related to fundamentals of care from Week 1 learning materials.
The first 3 nursing problems have been identified and are included in the template. These nursing problems cannot be changed and a care plan needs to be developed for each.
Your task is to identify another 2 priority nursing problems related to fundamental care needs and for each of the 5 nursing problems identify:
• The underlying cause or what the nursing problem is related to
• Goal of care
• Specific bedside nursing interventions you will do
• The rationales for your nursing interventions and actions
• Indicators that your plan is working
Notes for Task 2 only
• Read beyond the set texts to prepare the nursing care plan. JBI and Nursing Reference Centre may be used for the care plan (but not the other tasks) along with appropriate journal articles.
• Online nursing care plans are NOT acceptable and will not be accepted as references.
• Dot points may be used in the care plan template
• Rationales must be appropriately referenced
(900 words, 40 marks)
Task 3: Medication management
Three important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications, understanding the nursing responsibilities and how to monitor the patient to ensure they are responding to prescribed medications as they should.
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice,
• Briefly explain why Jim has been prescribed:
o Oseltamivir 75mg orally bd
o Paracetamol 4/24 orally prn
o Fluvax IM stat dose
AND
• Identify and explain
o The specific nursing responsibilities associated with administering each medication
o How you will monitor Jim for expected, side and adverse effects of each medication.
(300 words, 10 marks)
Task 4: Patient teaching
You recognise part of your nursing role is to provide Jim with education on:
o Preventing and controlling the incidence and spread of influenza
o Reducing the modifiable risk factors for hypertension
o Health promotion and minimising risk of hospitalisation
Select one (1) of the topics above and, in grammatically correct sentences and topic paragraphs,
• Identify the specific information you will need to explain to Jim about the topic
AND
• Explain
o Why the topic is an important aspect of Jim’s care
o How you will ensure that Jim knows and understands why it is important and, if appropriate to the topic, what he needs to do
(200 words, 10 marks)
Task 5: Clinical judgement and handover
There are two (2) parts to Task 5.
Part A:
Day 3 post admission:- Jim has tested positive for Influenza A and his influenza symptoms have decreased over the past 24 - 48 hours with continued medications. Jim is scheduled for discharge once he has completed his course of antiviral medication.
This morning on your shift you notice Jim seems more unsettled than usual. He has refused to get out of bed and he keeps calling out for blankets as he states is feeling cold. He has slept on and off for most of the morning.
When you enter his room to attend to routine vital sign observations you notice him curled up in bed shivering. His breathing appears laboured and he is diaphoretic and slow to respond when you speak to him.
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Vital signs
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Temperature
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39.6oC
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Heart rate
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125 beats per min
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Respiratory rate
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24 resps per min
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Blood pressure
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124/79 mmHg
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O2 saturations
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86% on room air
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In grammatically correct sentences and topic paragraphs,
• Identify
o What you think is happening
o Your immediate nursing actions and interventions
o The reason for your actions and interventions
Part B:
An important legal requirement of nursing practice is to effectively and succinctly communicate relevant information, actions and outcomes related to patient care and provide an accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.
Using the ISBAR format, information from the handover you initially received and the additional information above:
• Write a written handover for the oncoming shift that clearly and succinctly outlines the important information they need to know about Jim for continuation of nursing care.
Your handover must:
• Demonstrate person-centred care
• Adhere to the legal and professional nursing standards for documentation
• Be in appropriate professional language
• Contain NO abbreviations or nursing jargon
Attachment:- Medical Surgical Nursing.rar