Gavin a 24year old male was admitted to your ward from the emergency department during your afternoon shift for observations and further investigations of his neurological symptoms.
Gavin was celebrating Australia Day with mates at Florence Falls.
Please complete the assessment task on the next page.
Assessment 1: Topic
Nursing care of a person with altered neurological system
This is Gavin
You will be caring for him today.
—
Shift handover:
Gavin a 24year old male was admitted to your ward from the emergency department during your afternoon shift for observations and further investigations of his neurological symptoms.
Gavin was celebrating Australia Day with mates at Florence Falls. After a day of drinking alcohol he jumped into the waterfall from an unknown height and hit his head on rocks. Friends stated he was dragged from the water immediately and that there was a brief loss of
consciousness and he has numerous cuts and abrasions. His friends confirm Gavin drinks a case of heavy beer most days after work and binges on the weekends.
Gavin was brought in by ambulance to the emergency department with spinal precautions in place due to mechanism of injury. He has an altered Glasgow Coma Scale with altered sensation in his lower extremities. He also had multiple cuts and abrasions and excessive sunburn to his face chest and back.
In the emergency department Gavin has had a CT scan of his head and spine which has not detected anything abnormal. However due to his level of intoxication confusion and sensation deficit to lower extremities he is to be admitted to the medical ward for further investigations and observations.
Prior to transfer his observations have been charted and remain stable;
GCS14 (E4 V4 M6) PERL 4+ R/L BP 130/70 SaO2 99% on 2L O2 via nasal prongs
Temp 36.6OC BGL 5mmol/l HR 98 regular Neurovascular observations are
C=normal W= warm M=active S=partial
AWS 5 Pain score 5/10 RR 14 Generalised pain to head and torso
*PERL = pupils equal reactive to light
Medical orders
hourly neurological and neurovascular observations
spinal precautions to remain in place
nil by mouth with fluid balance
Alcohol Withdrawal Scale observations with prescribed pharmacological treatment
Medications orders
intravenous maintenance fluids Normal Saline (0.9% sodium chloride) 1000mls over
12 hours
Antiemetic IMI metoclopramide prn
Analgesia oral paracetamol 4/24 and S/C morphine prn
Benzodiazepine oral Diazepam prn as per the AWS scale regime
Assessment 1 Tasks:
Using the template provided in the Assessment 1 folder 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 6 tasks.
Do not make up or assume information in relation to or about Gavin. Only use what you know from the information you received today.
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.
Task 1:
Based on the handover information and in grammatically correct sentences identify;
Your three (3) nursing priorities to ensure you are prepared to received admit and provide immediate care to Gavin on admission.
AND
For each priority above identify
What it is related to?
Why it is a priority for you today?
(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 Gavin. Your plan must address the physical functional and psychosocial aspects of care.
For each nursing problem on your plan identify your
Goal of care
Interventions
Rationales for interventions
Expected outcome of care
Notes for Task 2 only
Dot points may be used in care plan template
Appropriate professional language must be used no abbreviations or nursing jargon
Rationales must be appropriately referenced. It is strongly recommended only current reliable journal articles be used as references when providing rationales
(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 and how to monitor the patient to ensure they are responding to the prescribed medications as they should.
In grammatically correct sentences briefly explain why Gavin has been prescribed
o Paracetamol orally o Diazepam o Normal Saline (0.9% Sodium Chloride) AND
Explain o The nursing responsibilities associated with administering the three (3) medications/fluid above
o How you will assess or monitor Gavin to ensure he is responding appropriately to these three (3) medications/fluid you are administering today?
(350 words 10 marks)
Task 4:
Patient has deteriorated and needs transferring
Using ISBAR and incorporating the additional information below prepare a written handover for the nurse taking over Gavins 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.
During your shift you notice the following observations
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