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Intent: The purpose of the assessment is to enable students to apply clinical reasoning and critical thinking to justify appropriate nursing actions and rationales when developing a nursing care plan.

Objective(s): This assessment task addresses subject learning objective(s): A, B, C, D and E This assessment task contributes to the development of graduate attribute(s):

Weight: 40%

Word count – 1800-word limit +/- 10%, excluding references (500 – 600 words per Nursing Diagnosis)

Task: This assessment is the development of a Nursing Care Plan Choose one of the case studies from the tutorial and lab sessions in the Medical Surgical Nursing subject and develop a nursing care plan.

The nursing care plan will include:

Identification of three nursing diagnosis from the case study that Registered Nurses can address. You may include ‘Actual’ or ‘Risk’ nursing diagnosis (please refer to the Nursing Diagnosis definition on page 2 of these guidelines).

For each nursing diagnosis:

• Identify a person-centred goal of care

• Three nursing actions

• Clear rationale for each nursing action

• Evaluation strategies to determine the effectiveness of nursing actions

The goals, nursing actions, rationale and evaluation strategies must be supported with high quality current literature where appropriate. For example: text books, peer-reviewed journal articles, health policy documents, government reports. Students need to demonstrate their ability to write clearly and succinctly to reflect their understanding. Accurate referencing is expected, poor referencing will result in loss of marks. Marks may be deducted if the assessment is not within the word limit.

Nursing diagnosis definition:

A nursing diagnosis is a problem that becomes apparent following a thorough and systematic interpretation of subjective and objective data. An actual nursing diagnosis consists of the person’s problem, the related aetiology (causal relationship between a problem and its related or risk factors) and supporting evidence/cues. For example: Dehydration related to post-operative nausea and vomiting evidenced by dry mucous membranes, oliguria, poor skin turgor, hypotension and tachycardia. A risk nursing diagnosis is a clinical judgment about a potential problem where the presence of risk factors indicates that a problem may develop unless nurses intervene appropriately. A risk diagnosis is written in two parts and does not include signs and symptoms.

1

Cardiac Case Scenario – David Parker

Handover Report (ED to Ward 6D- Cardiology) 20th April 2020 @ 1500

MRN: 365 555 DOB: 26.06.1955

Introduction

This is David Parker, a 64-year-old male who was brought in by ambulance following an episode of chest pain whilst

working on his farm at home. David’s wife Sophie and one of their employees, did not witness the initial chest pain incident

but had found David clutching his chest in agony in the farmhouse, collapsed on the kitchen floor. David had stated that

the onset of chest pain commenced whilst he was out in the paddock fencing @ 10:00hrs. Sophie phoned the ambulance

against David’s wishes due to his rising anxiety and concern regarding the farm. David’s wife and two children accompanied

him to the emergency department.

Situation

On examination in the ED upon arrival @ 12:00hrs, David initially presented looking pale and diaphoretic, breathless, alert

and orientated but experiencing obvious distress, tachycardic and hypertensive, complaining of nausea, and suffering from

pain radiating to his left arm, neck and teeth areas. His central chest pain had been constant lasting for roughly two hours

from onset and David is currently experiencing a score of 8/10 requesting pharmacological analgesic relief in the ED. A

STAT dose of IV Morphine is administered post insertion of a size 18 cubital Fossa Intravenous Cannula (CF IVC). An urgent

ECG is performed on David by the admitting Nurse which shows ischaemic injury (ST elevation) in the anterior leads. David

does not have any PmHx risk factors of head injury, malignancies, stroke or gastric bleed and progresses towards

thrombolytic treatment administration. A confirmed diagnosis of an acute Myocardial Infarction is the admission reason

for David, also known as STEMI (ST-Elevation Myocardial Infarction). David has an elevated Troponin level at 0.25g/L.

Background

David is an aboriginal man who lives at home on his sheep farm in regional NSW with his wife Sophie and their two young

children. PmHx includes: Osteoarthritis, hyperlipidaemia, hypertension (HTN) usually well-controlled, Type II Diabetes

Mellitus (T2DM) (Diet controlled), ETOH (Ethyl alcohol) usually drinks three bottles of wine per week and smokes one

packet of cigarettes per week.

Assessment – Observations are as follows

– BP 150/90

– HR 108 BPM

– SaO2 95% on RA

– RR 24

– Temp 36.8⁰C

– GCS 15/15 (E=4, V=5, M=6)

– Pain Score 8/10

– BGL 14.1mmol/L

2

Recommendations

The Emergency Department Medical Officer has transcribed a clinical plan as follows:

• Insertion of CF IVC

• Formal Bloods including: Formal Full Blood Count, Formal Urea, Electrolytes, Creatinine (UEC’s), Troponin Level

• Arterial Blood Gas

• Commence & titrate Glyceryl Trinitrate Infusion (GTN) to blood pressure and pain Maintaining DBP >60mmHg

• Morphine 2.5mg IV PRN

• Commence Thrombolytic treatment rTPA (Alteplase)

• Monitor GCS and vital observations please

• Consider Alcohol Withdrawal Scale (AWS)

• IV fluids 80mls/hr as charted

Additional: He is concerned about his farm and sheep at home. David is becoming increasingly agitated and impatient with

his family and rudely giving abrupt orders towards staff caring for him.

Charts available:

• SAGO & Neurological Observations Chart

• AWS Chart

• Fluid Balance & Fluid Order Chart

• Medication Chart

Medical Surgical Nursing 92438, 92454, 92450 Autumn 2020

Case Study Nursing Care Plan Weight: 40% Assessment due 20th May 2020 at 17.00 hours

Criteria HD High Distinction D Distinction C Credit P Pass U Unsatisfactory

Diagnosis Nursing diagnosis identified

•Three accurate nursing diagnosis identified and comprehensive, correct expression provided

•Three accurate nursing diagnosis identified and correctly expressed in detail

•Three accurate nursing diagnosis identified and correctly expressed

•Three accurate nursing diagnosis identified

•Less than three accurate nursing diagnosis identified

Actions Goal and nursing actions identified and described

•A person-centred goal of care is identified in detail •3 appropriate nursing actions described comprehensively

•A person-centred goal of care is identified in detail •3 appropriate nursing actions described in detail

•A person-centred goal of care is identified. •3 appropriate nursing actions described.

•A person-centred goal of care is identified. •2 -3 appropriate nursing actions described.

•A person-centred goal of care is identified. •Less than 2 appropriate nursing actions described.

Rationale Rationales identified and discussed

•A clear and comprehensive rationale for each nursing action discussed in detail.

•A clear rationale for each nursing action discussed in detail

•A clear rationale for each nursing action discussed.

•1-2 of the rationales for each nursing action are unclear and need more development.

•Rationales for each nursing action are unclear and/or rationales for each nursing action are not discussed

Evaluation Evaluation strategies identified and explained

•Evaluation strategies to determine the effectiveness of nursing actions are comprehensively explained for each nursing action

•Evaluation strategies to determine the effectiveness of nursing actions are explained in detail for each nursing action

•Evaluation strategies to determine the effectiveness of nursing actions are explained for each nursing action

•Evaluation strategies to determine the effectiveness of nursing actions are described but explanation needs more development.

•Evaluation strategies to determine the effectiveness of nursing actions are unclear and not explained

Medical Surgical Nursing 92438, 92454, 92450 Autumn 2020

Writing Writing is clear and coherent (including appropriate sentence structure, spelling and grammar). Evidence of in-text referencing

•Writing is clear and coherent •Correct paraphrasing and referencing are evident.

•Writing is clear and coherent •Correct paraphrasing and referencing are evident, minimal errors.

•Writing is clear and coherent •Correct paraphrasing and referencing are evident, minimal errors.

•Writing is clear and coherent •Correct paraphrasing and referencing are evident, some minor errors present.

•Writing is unclear and requires development •Correct paraphrasing and referencing are not evident, multiple errors present.

Referencing Evidence of in-text referencing and reference list provided

•At least six different references are utilised, 4-5 high quality references •An accurate reference list is provided.

•At least six different references are utilised, 3-4 high quality references •An accurate reference list is provided, minimal errors.

•Six different references are utilised, 2-3 high quality references •An accurate reference list is provided, minimal errors.

•Six different references are utilised, 1-2 high quality references • Reference list is accurate, some minor errors present.

•Less than six different references are utilised •Reference list provided is not accurate, multiple errors present.

Medical Surgical Nursing 92438

Assessment one: Nursing Care Plan Weight: 40% Due: Monday 28th September 2020 by 5pm Read the assessment guidelines carefully before commencing your assessment item.

If you are unclear about any aspect of the assessment item please speak to your tutor before you commence writing.

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Nursing Diagnosis 1 9-10 8 7 5-6 0-4

 Accurate nursing diagnosis identified and correctly expressed.

 A person-centred goal of care is identified.

 3 appropriate nursing actions described.

 A clear rationale for each action discussed.

 Evaluation strategies to determine the effectiveness nursing actions

explained.

 Nursing actions, rationales and evaluation strategies for determining

effectiveness are accurate and supported by evidence from high

quality sources.

 Writing is clear and coherent (including appropriate sentence

structure, spelling and grammar).

 Correct paraphrasing and referencing are evident.

Nursing Diagnosis 2 9-10 8 7 5-6 0-4

 Accurate nursing diagnosis identified and correctly expressed.

 A person-centred goal of care is identified.

 3 appropriate nursing actions described.

 A clear rationale for each action discussed.

 Evaluation strategies to determine the effectiveness nursing actions

explained.

 Nursing actions, rationales and evaluation strategies for determining

effectiveness are accurate and supported by evidence from high

quality sources.

 Writing is clear and coherent (including appropriate sentence

structure, spelling and grammar).

 Correct paraphrasing and referencing are evident.

Medical Surgical Nursing 92438

Nursing Diagnosis 3 9-10 8 7 5-6 0-4

 Accurate nursing diagnosis identified and correctly expressed.

 A person-centred goal of care is identified.

 3 appropriate nursing actions described.

 A clear rationale for each action discussed.

 Evaluation strategies to determine the effectiveness nursing actions

explained.

 Nursing actions, rationales and evaluation strategies for determining

effectiveness are accurate and supported by evidence from high

quality sources.

 Writing is clear and coherent (including appropriate sentence

structure, spelling and grammar).

 Correct paraphrasing and referencing are evident.

Overall quality of referencing 9-10 8 7 5-6 0-4

 At least six different high quality references are utilised e.g. (peer-

reviewed journals, textbooks, health policy documents, government

reports).

 An accurate reference list is provided.

 No more than 10% direct quotes.

Note: The difference in marks for each section of this rubric will be determined by how well each of the specified

elements are addressed.

Assignments with significant Turnitin matches indicative of poor referencing and paraphrasing will receive zero marks

for the relevant section(s)

TOTAL /40

Feedback:

Marker’s name: Date:

Name of patient:Name of case study:Day of Admission:
[Actual] Nursing Diagnosis 1:
Goal of careNursing actionsRationale for actionsEvaluation strategies to determine effectiveness of actions
1.
2.
3.
Name of patient:Name of case study:Day of Admission:
[Actual] Nursing Diagnosis 2:
Goal of careNursing actionsRationale for actionsEvaluation strategies to determine effectiveness of actions
1.
2.
3.
Name of patient:Name of case studyDay of Admission:
[Risk] Nursing Diagnosis 3:
Goal of careNursing actionsRationale for actionsEvaluation strategies to determine effectiveness of actions
1.
2.
3.

Reference List

EXAMPLE of Assessment 3: Case Study Nursing Care Plan

Refer to the assessment one guidelines and rubric for further information about this assessment item.

• Although the example below does not have references your answers must be supported by evidence from at least

six different high quality sources such as peer-reviewed journal articles, textbooks, health policy, government

reports

• You are to identify your own nursing diagnoses, please do not replicate the ones below

EXAMPLE Name of patient: Mr John Smith

EXAMPLE Name of case study: Abdominal Surgery case study

EXAMPLE Day of Admission: 2

FOR EXAMPLE [Actual] Nursing Diagnosis 1:

Exacerbation of acute post-operative pain related to inadequate patient education evidenced by pain scores of 5-8.

Goal of care Nursing actions (HOW) Rationale for actions (WHY) Evaluation strategies to

determine effectiveness of

actions (How do you know

this has worked?)

The key goal of care

in relation to Mr

Smith’s nursing

diagnosis would be to

1. The first nursing action would be to

complete a thorough pain assessment

using the P Q R S T mnemonic:

A comprehensive pain assessment will

ensure that the nature and extent of Mr

Smith’s pain is fully understood. A pain

assessment will also help to determine

I would assess Mr Smith’s

pain and within one hour

following my nursing actions

I would expect Mr Smith’s

effectively manage

his pain so that his

pain score is 4 or less

and he is able to

mobilise, take deep

breaths, cough and

engage in activities of

daily living with

minimal discomfort.

P – Factors that precipitate or provoke

the person’s pain

Q – Quality and character of pain (e.g.

aching, burning, crushing etc)

R – Region (location) of pain and does it

radiate to or from other parts of the

body

S – Severity – rate intensity of pain

using appropriate pain scale

T – Time – onset and duration of pain.

The pain assessment would also include

a medical review of the analgesia

medication(s) on the patient medication

chart, checking the patient Peripheral

Venous Cannula (PVC) to ensure

patency.

the cause of the pain and whether it is

related to poorly managed post-operative

surgical pain or IV Cannula malfunction or

indicating a post-operative complication.

pain to be 4 or less and he

should be able to mobilise,

take deep breaths, cough

and engage in activities of

daily living with minimal

discomfort.

2.

3.

EXAMPLE Name of patient: Mr John Smith

EXAMPLE Name of case study: Abdominal Surgery case study

EXAMPLE Day of Admission: 2

FOR EXAMPLE [Risk] Nursing Diagnosis 1:

Risk of deep vein thrombosis (DVT) related to limited mobility and dehydration

Goal of care Nursing actions (HOW) Rationale for actions (WHY) Evaluation strategies to

determine effectiveness of

actions (How do you know

this has worked?)

It is important to

prevent DVTs rather

that manage them

after they have

occurred.

1. To prevent the likelihood of Mr Smith

getting a DVT, I would administer a

prophylactic anticoagulant as ordered

by the medical officer.

Prophylactic anticoagulant medications

such as enoxaparin sodium or heparin are

designed to inhibit the coagulation

cascade by inhibiting the conversion of

fibrinogen to fibrin and thus preventing

the formation of thrombi.

I would assess Mr Smith’s

lower limbs daily checking

for redness or discoloration,

pain or swelling as these

signs may be an early

indication of a DVT. The

preventative actions

initiated should ensure that

none of these signs are

evident.

2.

3.