This written assessment asks students to use the clinical reasoning process and refer to evidence based practice to formulate a nursing plan of care for a specific case study selected. After reflecting upon, analysing and researching the information provided in the case study, students will address each of the following tasks:
1. Critically analyse the patient assessment findings, taking into consideration the person’s situation and medical diagnosis. Discuss the data/information collected and process that information in terms of relevance to their nursing care using DRABC ( danger, response, airway, breathing, circulation) (10 marks)
2. Identify three (3) nursing diagnoses for this person;
One of which must address the client’s psycho-social needs.
The nursing diagnoses must be discussed in order of priority (e.g.: what nursing diagnosis should be addressed first and why).
You must also establish one patient centred goal for each nursing diagnosis. (5 marks)
3. For each nursing diagnosis,
discuss the specific nursing interventions (what you would do and why) that would be appropriate.
Each intervention must include detailed rationale (why you did what you did) and specific evaluation criteria (how will you know if the intervention was successful).
Your nursing interventions must be person or family centred and must be specific to this client (e.g., tailor the intervention to meet the needs of this specific patient based on evidence and professional recommendations).
All interventions must be referenced from professional literature. (20 marks)
The quality of your academic writing will be assessed throughout each of these three sections and will contribute to your overall mark for that section.
Please see 6h for specific guidelines for formatting an academic paper. Additional marks will be awarded for using correct APA format and referencing throughout your paper (5 marks).
You are a student nurse assigned to a morning shift on a general surgical ward of an acute care facility. You arrive early, before the shift starts, to review your patients’ notes in order to better plan your nursing care. Please select one person from the two listed to complete your written case analysis report using the information provided below.
Case Study 1
You are caring for Mr. Harry Flanagan who is Day 4 since his admission to hospital.
Presenting History
Mr. Harry Flanagan is a 24 year old man who was a passenger in a car involved in a head-on
collision with another car. Harry’s car was travelling at approximately 60 km/ hour. Harry
arrived at the Emergency Department about 35 minutes after the collision. He was not trapped
in the car, although the ambulance were required to extract him, because he couldn’t move his
left leg because of the pain and because of other potential injuries.
Medical History
Harry has no significant medical history. He is normally fit and healthy. He has no allergies.
Social History: Harry is employed as a real estate agent; he has just bought an apartment and
has recently become engaged to his partner Janelle. They have an 18 month old daughter,
Sophie. Harry moved to Canberra from Alice Springs three years ago to play rugby.
Day 1, 3.30 pm: Arrival in ED :
Vital Signs:
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