Length: 2000 words
Assessment purpose: Are developing appropriate critical thinking, clinical reasoning and sound clinical decision making processes and strategies essential for safe, evidence-based and competent nursing practice in medical surgical settings
Presentation
Assessment is to be submitted and presented:
Referencing Students are reminded of their academic responsibilities and professional nursing practice requirements when using the work of others in assignments. Reminder marks are allocated for academic integrity.
Assessment: Case scenario
Sonya, a 45year old female, is being admitted to your ward from the emergency department during your afternoon shift for observations, treatment and further investigations of her urinary and renal symptoms. Sonya was referred to the local hospital by her GP after returning 5 days ago from her honeymoon overseas with a urinary tract infection (UTI). Her primary concern was dysuria and frequent scant urination. Sonya was prescribed an oral antibiotic for 5 days and rest. On assessment Sonya stated 3-4 days of fevers with rigors, lower back and flank pain which is not responding to regular paracetamol, nausea with intermittent vomiting and lethargy. She has been unable to tolerate oral intake for over 24 hours and her urine remains dark and offensive. In the emergency department the preliminary diagnosis of pyelonephritis was made by the medical team but confirmation is pending pathology results and renal ultrasound. Sonya has a past medical history of hypertension, hyperlipidaemia and renal calculi but has been unable to tolerate her regular medications. She has a documented allergy to penicillin. Prior to transfer her observations have been charted and remain stable:
Vital signs Urinalysis
Glasgow Coma Scale | 15 alert & orientated |
Blood Pressure | 110/60mmHg |
Heart Rate | 117bpm regular |
Oxygen saturation | 99% on nasal prongs@2L |
Respiratory rate | 18bpm |
Pain score | 5/10 |
Temperature | 38.6oC |
Output | 30mL/hr cloudy & dark |
LEU | Positive |
NIT | Positive |
URO | Negative |
PRO | Positive |
pH | 6.0 |
BLO | Positive |
SG | 1.005 |
KET | Negative |
BIL | Negative |
GLU | Negative |
Medical orders
Medications orders
Assessment Tasks: Using the template provided and, 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 tasks. Do not make up or assume information in relation to or about Sonya. Only use what you know from the information you received today.
Task 1:
Based on the handover information and in grammatically correct sentences identify
(200 words, 5 marks)
Task 2:
Based solely on the handover you have received and using the template provided, develop a full nursing care plan for Sonya. Your plan must address the physical, functional and psychosocial aspects of care.
Note: Students are expected to demonstrate they have read beyond the set texts to prepare their nursing care plan. Reliance on text books alone is no guarantee that your information is current and reliable evidence for practice. However, set texts are a good place to start to identify key points and to develop search strategies to locate appropriate journal articles.
For each nursing problem on your plan you need to identify what it is in relation to and your:
Notes for Task 2 only
(750-1000 words, 30 marks)
Task 3:
Two important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications, how to monitor the patient to ensure they are responding to the prescribed medications as they should and identify any contraindications with medication type or administration choice.
(350 words, 10 marks)
Information needed for Tasks 4 and 5
You will need to use the following information to complete tasks 4 and 5 (this information is for these tasks only). During your shift the following occurs:
Vital Signs
Glasgow Coma Scale | 14 confused and disorientated |
Blood Pressure | 95/50mmHg |
Heart Rate | 135bpm thready & irregular |
Oxygen saturation | 96% on Hudson mask@6L |
Respiratory rate | 26bpm |
Pain score | Unable to assess score– verbal groans only |
Temperature | 39.9oC |
Output | <25mL/hr dark, cloudy, purulent, offensive |
Capillary refill | >3sec, pale, poor skin turgor |
Task 4:
Based on what has occurred during your shift (see previous page) address the following:
AND
(200 words, 2.5marks)
Task 5: Clinical communication – handover ward transfer
Using ISBAR and incorporating the additional information from the previous page prepare a written handover for the nurse taking over Sonya’s care in ICU. Handover must address the physical, functional and psychosocial aspects of care and reflect any changes required to your nursing care plan above. You must use appropriate professional language with no jargon or abbreviations.
(250 words, 5 marks)
Task 6:
An important part of the clinical reasoning process is to reflect on what you have done and learnt as well as to help you understand the concepts of holistic nursing practice.
(200 words, 2.5 marks)
Notes for Task 6 only
Reflective writing is the opportunity for you to document your thoughts and feelings. This requires a different writing style to the rest of the assignment.
As you are expressing your thoughts and feelings, you write in the first person. It is expected to see words like “I” and “my“ and phrases like “I have learnt…”, “I now understand or realise that…”
It is not appropriate to reference your own personal thoughts and feeling. However, if you refer to professional nursing standards and codes, information from specific sources (eg a text book or journal) or draw on your understanding of the role and scope of practice of the registered nurse, you must provide a reference to support your statements.