NURBN1017 Nursing Practice 2: Nursing Assessment and Management

Task Instructions

Weighting:

This case-based written analysis contributes 40% of your overall grade.

Word Count:

This case-based written analysis has a word count limit of 1600 words (+/-10%)

Submission Due Date:

Monday, September 25, 2023, @ 0900hrs via Turnitin.

Purpose

This written analysis of this case-based scenario aims to develop the capacity to identify, research, and critically analyse the key concepts of person-centred care within the scope of the NMBA Nurse Standards for Practice and to assess nursing attributes for this course. Please refer to these in the course descriptor. This assessment task also aims to help you learn and apply the clinical reasoning cycle.

Description:

This written assessment should demonstrate your knowledge and application of the best evidence- based nursing practice in relation to nursing assessment, person-centered nursing care and documentation, as well as the development of application of the clinical reasoning cycle. You are required to submit a 1600-word, fully referenced written analysis directly related to the case scenario provided. Please refer to the assessment section of Moodle for details of the case scenario and specific assessment instructions, including the marking criteria and submission details.

Formatting, Presentation and Referencing:

Your report must include the following:

• A cover page including the assessment title, due date, relevant academic, student name and student ID number
• An introduction
• A body including the use of headings - headings are to be bolded and left aligned.
• A conclusion
• Referencing - intext citations and a reference list formatted according to APA 7th edition requirements
• Minimum of eight references no older than seven years old unless of historical significance and/or of specific relevance to the topic (for example; the Ottawa Charter from 1986)
• These references must be a mixture of books and journals or Library database sources. Dictionaries, Wikipedia, Webpages and Yellow Pages are not considered a primary reference and therefore will not be counted in the reference count
• 1600 words (+/- 10%), report will only be marked up to this + 10% word limit - Direct quotes, appendices and the reference list, are not counted in the word limit. Direct quotes must be limited to no more than 50 words and be according to APA 7th Edition style
• 12 point Times New Roman or Arial font
• Double spacing and block paragraphs
• Page numbers to be included on the bottom left corner of the page
• Shortened assessment title as a header on the top left and your name as a header on the top right
• Do not use dot point or write in first person unless indicated to do so
• file name includes the Course Code, Surname and Student ID number. For example, NURBN1013 Smith Ensure there are no spaces or use of punctuation (!?/; _-)

Please note that marks may be deducted if your assessment does not conform to these instructions.

For further assistance in relation to academic writing and referencing, please refer to the Assessment and Orientation sections of Moodle and/or the library homepage.

Read    

NURBN1017 Case Scenario

You are a first-year student nurse completing your placement in an emergency department. You are commencing a morning shift, and you and your buddy nurse are receiving a handover from the night staff about Mrs Reynolds.

The following is the ISBAR handover you will receive from the night nurse.

Identify- Hi, Mrs Reynolds; I am just about finishing my shift and would like to handover to

the morning staff. Is that ok? This is the student nurse, and he/she will be working with their buddy registered nurse, who will be your morning nurse. This is Mrs Reynolds. She is a 74-year-old female admitted to us with shortness of breath and fever this morning.

The night shift nurse and you cross-check patient identifiers by asking the patient and checking her ID and medical records.

Situation- Mrs Margaret Reynolds was admitted with complaints of shortness of breath and stated that she was feeling hot. 

Background- Mrs Reynolds has a history of hypertension, mild osteoarthritis, and depression. All her regular medications are charted. She lives alone and has a pet dog. Her adult children live on the other side of the city and are more than happy to be called any time of the day.

She does get council help for cleaning and shopping, and she enjoys cooking. 

Assessment- Mrs Reynolds is complaining of feeling hot and short of breath. She stated that

she hasn’t had any sleep last night.

General appearance- Mrs Reynolds appears anxious and fatigued. She is sitting upright and leaning forward to breathe comfortably.

Airway: The airway is patent and clear without any obvious obstructions. The patient can speak.

Breathing: Her breathing is spontaneous. She is talking in short sentences and displaying signs of shortness of breath. RR-24 breaths/minute, oxygen saturation was 93% on room air and 96% on 2L of O2 via nasal prongs. Lung sounds reveal bilateral crackles and decreased air entry on the bases of the lungs on auscultation. She is COVID-negative and has a moist productive cough with greenish-yellow sputum.

Circulation: Temperature at the handover time is 37.9⁰ C. Heart rate is 98beats/minute and is regular. BP is 150/90 mmHg. Capillary refill time is under 3 seconds. Skin looked dry and poor skin turgor.

Disability: She is alert and oriented to place but confused about the time, the date and the day. She is pain-free but has been complaining of decreased appetite and nausea. She is normally continent and ambulates to the toilet.

Recommendations/Request: The treating team reviewed her this morning, and she has been diagnosed with pneumonia. For dietician and physiotherapy referral.