Assessment 1 Case study

Assessment 1 Case study . Kylie Melville is a 47 year old female who has a history of ‘not being able to breathe well through her nose’, and this disrupts her sleep. Kylie also states that if she exercises or exerts herself, she ‘cannot get enough air in’ and has to mouth-breathe, using breathing techniques to take deep, slow breaths to stabilise her breathing pattern, so that she does not go dizzy. Kylie has a history of sensitivity to codeine (which causes nausea, dizziness, temperature flushes and malaise), is not on any medication, and has no other medical conditions. After review by the specialist ENT surgeon, it was arranged for Kylie to undergo surgery for a septoplasty and right ethmoidectomy. On arrival pre-operatively Kylie’s observations were: T-36.7oC, HR-74bpm, RR-18pm, BP121/71mmHg, O2-94% RA You are a student nurse looking after Kylie since her return to the ward post-operatively at 10:30hrs. IV Compound Sodium Lactate 1L is running at 6/24 rate into Kylie’s left arm. Kylie’s anaesthetist has prescribed Paracetamol 1g IV/PO 6 hourly, Celecoxib 200mg PO BD, and Tramadol SR 100mg PO BD prn, bung IVT when current bag completed. She is awake and alert, and has a nasal bolster under her nose, with moderate sanguineous ooze. Kylie’s RTW observations were: T-36.1oC, HR-75bpm, RR-19pm, BP-107/70mmHg, O2-91% RA, and pain score 2/10. Assume nothing, if data is not stated, you should state that it is not known or information has not been provided, and advise what actions you would take.

Students are required to research and write a case study essay with headings, directly relating to the above scenario. Using the nursing process, outline the nursing management for the patient post-surgery, discussing all care in general, but focussing on the two (2) prioritised nursing diagnosis/ problems.

Assessment 1 Case study

In preparation for the assignment, students are encouraged to make a list of all assessment data – including objective and subjective data, considering all of the body systems, and functional health/ ADLs, post-operative specific, surgery-specific, patient-specific, and what further information would be required to be assessed. From this list, students are encouraged to develop a list of actual and potential issues/ problems/ risks for all assessment data, from which they should identify which of these are their two prioritised issues, and what method was used to prioritise these. Then students are encouraged to complete nursing care plans (similar to the sample NCP) for each of the two diagnoses. This planning material is for student’s personal assignment planning only, and should not to be submitted with their essay. All of the information in this planning will then need to be discussed in the case study essay, in academic writing style.

Assessment 1 Case study

Presentation

• Format in accordance with School of Nursing & Midwifery guidelines (see BB Assessment tab).
• Academic writing style.
• Appropriate sentence structure, word use, grammar and spelling (this is an ELP specified unit).
• Logical flow. Students should format their essay management section with headings as:

Assessments; Nursing Diagnosis Priority 1: (name of nursing diagnosis) – with subheadings for

Planning, Implementation, Evaluation; and Nursing Diagnosis Priority 2: (name of nursing diagnosis)

– with subheadings for Planning, Implementation, Evaluation.

The assignment must flow smoothly and read logically for the reader.

Introduction (approx 100 words)

• A general overview of the topic and definition of terminology
• An outline of the paper

Background (approx 200 words)

Assessment 1 Case study

• This should be given as an iSoBAR handover (can be with iSoBAR headings, or in paragraph format in

iSoBAR sequence).

• From the information given in the scenario provide iSoBAR handover, given as though you are

updating the nursing team you are working with, after you had completing the first set of post-op

observations as is given in the scenario.

• For the iSoBAR handover, students may use first person to introduce themselves and their patient,

however all other information in the essay and background is to be in third person academic style.

Management (approx 1100 words)

• Using the nursing process, outline the nursing management for this patient post-surgery, discussing

all care in general, but focussing on two (2) priority nursing diagnosis/ problems.

• Ensure that each part of the nursing process is discussed within the essay, showing depth to show

critical thinking and coverage of each section.

Assessment 1 Case study

• Assessment – Students should demonstrate that they have looked at all of the assessment data (see

preparation paragraph above). Students are not to assume or make up assessment findings, if data

is not stated, you should state that it is not known or information has not been provided, and advise

what actions you would take. Discuss the assessment findings that have been given, what other

assessments that would be required, what appropriate assessment tools (eg Falls Risk, Braden Scale and Pain Assessment) would be used, and if any findings are not within normal parameters, students should identify this, and give a rationale why this is so.

• Nursing diagnosis – Students should discuss their two (2) prioritised nursing diagnoses in-depth (focus should be on post-operative care). After analysing all of the assessment data and patient’s responses that students have gathered above, students should consider the actual and potential nursing problems/ issues, and discuss why they have prioritised the diagnoses that they have (eg use of primary survey, use of first-aid DRSABCD, actual v potential, etc) – this should demonstrate the student’s ability to prioritise, not just choosing two nursing diagnoses that they wish to discuss.
• Planning – Students should demonstrate their three (3) prioritised plans of care for each nursing diagnosis. These should all utilise SMART goals (specific, measurable, achievable, realistic, and with timeframe), advising of planned outcomes and criteria that are required. Includes psychosocial outcomes and patient involvement in identifying planned outcomes.
  

  Assessment 1 Case study

• Implementations – Students should demonstrate at least three (3) prioritised implementations for each plan. Discuss all interventions and actions taken to meet the planned outcomes and achieve the SMART goals. This can be nursing interventions, documentation, referral to multidisciplinary team (nurse needs to ensure multidisciplinary team member has followed up). Each intervention should include the rationale why this intervention is required, and be supported with rationale (reference – see care plan in preparation). This also includes documentation in all areas required (which will become measured criteria from SMART goal as evidence in evaluation section).
• Evaluation – Evaluation of planned goals occurs throughout the entire nursing process, but is discussed at the end. Students should demonstrate their evidence of whether planned outcomes and goals were met (or not) – each goal requires an evaluation. If not, then why have they not been met, and whether re-evaluation is required at a later date, or plans changed. Students need to demonstrate how they know whether planned outcomes have been met – what is the evidence that goals have been met, what tools were used, where this is documented (usually documentation as evidence).

Assessment 1 Case study

 Potential complications and post-operative education (approx 200 words)

• Outline the potential complications that the nurse and patient should be aware of.
• Outline the post-operative education that would need to be provided to your patient, in order to promote a successful recovery.

Involvement of the interdisciplinary team (approx 200 words)

• Discuss all of the members of the interdisciplinary team, and which particular members that would be involved in your patient’s management of care, including what service that they will provide.

Conclusion (approx 200 words)

• Provides an overview of the assignment
• No new material introduced Referencing
• In-text and end-text referencing per current referencing guidelines – APA style.
• Minimum of 15 current and credible academic references, using a variety of sources (including a minimum of 4 journal articles and minimum of 2 quality websites).
• All sources are up to 5 years old.
• Recent and quality sources used – Wikipedia and Dictionary.com will not be accepted as a reference source!
• Medical dictionary used for medical terminology
  

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