NUR250 Nursing Care of A Patient In A Medical Surgical Setting-Charles Darwin University

Topic: Nursing care of a patient in a medical surgical setting

Length: 2000 words + 200 for words on template

NUR250 Nursing Care of A Patient In A Medical Surgical Setting

Contribution to overall grade:  40%

Assessment purpose Learning objectives 
Assessment 1 is the only written academic assignment in NUR250 for students to demonstrate they:

•       Are developing the ability to locate, interpret, integrate, synthesize and apply nursing knowledge from NUR250 to a relevant nursing practice scenario in medical surgical settings

•       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

•       Are able to focus their attention to the needs of the individual patient as the key concern of nursing practice in medical surgical settings

•       Are able to explain and justify or defend their nursing care decisions

•       Have a developing understanding of the role and scope of practice of the registered nurse in the Australian health care context

•       Are progressing towards the level of professional written communication required for nursing practice in Australia

•       Are demonstrating ethical and professional practice by adhering to the University’s academic integrity standards and plagiarism policy

 This assessment addresses the unit learning outcomes;

1, 2, 3, 4 and 5

NUR250 Nursing Care of A Patient In A Medical Surgical Setting: Assessment 1 S2 2017

Preparation  

  • Completion of study materials from weeks 1 to 6 with participation or review of online collaborate sessions and pre-recorded lectures.

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Presentation

  • On the Assessment 1 template located in the Assessment 1 folder on NUR250 Learnline  As a computer generated document in Word format.
  • 5 spaced using Arial, Times New Roman or Calibri font in size 11 or 12
  • In clear, coherent Australian English that demonstrates progression towards the standard for written communication for professional nursing practice in Australia
  • Using appropriate professional terminology
  • Contents page, title page, introduction and conclusion are NOTrequired
  • Unless otherwise indicated, no acronyms, abbreviations and/or nursing jargon
  • Unless otherwise indicated, grammatically correct sentences and topic paragraphs are required. Dot points only accepted in the nursing care plan
  • No more than 10% over or under the stated word count

oNote:  Headings, any task information copied in and in-text citations are included in the word count. 200 words have added to the word count to account for the headings within the nursing care plan template

  • Use of trade names is not acceptable. Only generic terms or names are to be used when referring to specific medications or other prescribed treatments or resources that may be used in nursing practice
  • Shift handover: Jim is a 58 year old homeless Indigenous male of no fixed address. He presented to the Emergency Department with dyspnea, myalgia, fatigue, malaise, rhinorrhea and headache. His symptoms began approximately 1 day ago and are continuous and steadily getting worse. On examination he was found to be febrile with a clear nasal discharge, shortness of breath and muscle soreness. He has a previous medical history of asymptomatic hypertension but is not currently prescribed antihypertensive medication as he did not take this medication when previously prescribed. Heis allergic to chickens but has no known drug allergies. He states he used to smoke but not so much anymore as he cannot afford them however he does smoke up to 5 – 10 per day if he can get them.
     

    Vital signs
    Temperature 38.3oC
    Heart rate 105 beats per min
    Respiratory rate 18 resps per min
    Blood pressure 158/86 mmHg
    O2 saturations 94% on room air
    		 

    Physical assessment
    General Thin, undernourished, clean, unshaven, distressed older male
    Ears, nose & throat Copious clear nasal discharge, red and inflamed tonsils and pharynx, ears clear
    Respiratory Wheezes bilaterally, no crackles
    Cardiac Regular rate and sinus rhythm, no murmurs, rubs or gallops
    Musculoskeletal No odema but overall muscle and joint tenderness
    Skin Hot and diaphoretic
    Neurological Alert and orientated, GCS 15/15
  • Jim has been given a preliminary diagnosis of Influenza while awaiting diagnostic results. He has been admitted to the ward and commenced on oseltamivir pending the results of his flu swab.Assessment 1:  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.

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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?

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 nursinginterventions 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

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 nursinginterventions 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

Task 4: Patient teaching

You recognise part of your nursing role is to provide Jim with education on:

oPreventing and controlling the incidence and spread of influenzaoReducing the modifiable risk factors for hypertension  oHealth 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 oWhy the topic is an important aspect of Jim’s care

oHow you will ensure that Jim knows and understands why it is important and, if appropriate to the topic, what he needs to do

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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.

Vital signs
Temperature 39.6oC
Heart rate 125 beats per min
Respiratory rate 24 resps per min
Blood pressure 124/79 mmHg
O2 saturations 86% on room air

In grammatically correct sentences and topic paragraphs,

  • IdentifyoWhat you think is happening oYour immediate nursing actions and interventionsoThe 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

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