Below case study is real life cases, with some embellishments.
\nCase Scenario \u2013 Vanessa Anderson
\nShift handover:
\nIdentify: Miss Vanessa Anderson, HRN: 123456, DOB: 25\/12\/2004
\nSituation: Vanessa is a 16yo, healthy active female living in Darwin who was admitted after experiencing a traumatic head injury after being struck on the R) side of her head, behind her ear by a golf ball at approx 0825.
\nParamedics attended and brought her into ED. She was sent for an urgent CT which diagnosed depressed focal right temporal skull fracture. Bone fragments in brain matter and dural lacerations present.
\nShe has been complaining of a headache and has a GCS of 14-15.
\nShe has been transferred to the CDU Neurological ward for continuing care, it is now Sunday 1300.
\nBackground: Vanessa lives with her parents and has an older brother Jason. She plays golf 3-4x a week and is in yr11 at High School.
\nPmh \u2013 Asthma \u2013 Seretide and Ventolin
\nAllergies \u2013 Shellfish and nuts
\n60kgs, normal BMI
\nAssessment: Airway: Own, patent
\nBreathing: RR 23, O2 Sats 98% on RA.
\nCirculation: HR 68bpm, BP 120\/65 mmHg.
\nDisability: GCS 14\/15, she is intermittently confused, PEARL 3mm, BGL 5.0mmol\/L
\nExposure: Temp 36.5 oC,
\nShe has 1 x PIVC inserted to her R) ACF, it is patent.
\nRecommendations\/Read back: Medical orders
\n\u2022 Routine ward assessments and observations
\n\u2022 4\/24 full neuro observations
\n\u2022 Administer analgesia as prescribed
\n\u2022 Diet and fluids as tolerated
\n\u2022 TED stockings and DVT prophylaxis
\nMedication orders
\n\u2022 Panadeine Forte 1000mg\/60mg QID
\n\u2022 Oxycodone 5mg PRN (Max dose 30mg in 24hrs)
\n\u2022 Phenytoin 100mg IV over 6hrs
\nNursing orders
\n\u2022 Devise a plan of care for your patient
\nThe following events transpired over the course of the next few shifts.
\nMonday
\n0830 Medical review.
\nGCS 15.
\nContinue with regular Panadeine Forte
\nOxycodone changed to 5-10mg 3hrly PRN
\nYou return on Monday for the nightshift, and you are allocated to care for Vanessa.
\n2100hrs \u2022 handover at 2100hrs you are told that Vanessa last had the following analgesia.
\n\u2022 – Panadeine Forte
\n\u2022 \u2013 PRN Oxycodone 10mg
\nYou perform your assessment and note the following:
\nAirway: Own, patent
\nBreathing: RR 16, O2 Sats 96% on RA.
\nCirculation: HR 62bpm, BP 105\/58 mmHg.
\nDisability: GCS 14\/15, she is intermittently confused, PEARL 3mm, BGL 6.0mmol\/L
\nExposure: Temp 36.2 oC,
\n2300hrs Vanessa rings the bell and complains of a continual headache, you administer:
\n2300 \u2013 PRN Oxycodone 10mg
\n0000hrs You review Vanessa, and she complains of no improvement in her headache; pain is 9\/10; you administer her scheduled Panadeine Forte.
\n0100hrs At 0100 Vanessa rings her bell for Helpance; she tells you, in a distressed voice, that she cannot move.
\nYou attempt to do a full set of neurological observations and ask Vanessa to lift her arms, she cannot, she is frightened. There is no shaking, no stiffness to her limbs and her breathing is normal. She feels warm to touch and has a normal skin colour. You do not assess any other limbs nor do you assess her GCS.
\nYou do not believe she is in immediate danger and assume she has had a bad dream. You offer reassurance and leave the room as you urgently have a new admission you must attend to.
\nWithin 10 minutes you return to Vanessa and perform a full set of neurological observations, with no deficits noted, you are happy with your original assumption that she had a bad dream.
\n0200hrs Vanessa rang the bell to ask for Helpance to use the toilet, she is able to mobilise with some Helpance.
\nHer pain remains unresolved, you give her PRN Oxycodone 10mg.
\n0400hrs You have routine and neurological observations to conduct but as she was ok when you walked her to the toilet 2hrs you decide to not conduct these.
\nHer Dad arrived on the ward at 0345 and he is fast asleep in the chair in her room, you decide not to disturb them as she is finally settled after her analgesia.
\n0530hrs You go to check on Vanessa and find her unresponsive.
\nYou initiate a MET call.
\n0635hrs Vanessa is pronounced dead, despite all attempts to resuscitate her.
\nCoroners review \u2013 cause of death. Post-mortem:
\n\u2022 Blunt head injury and mechanism of death most likely a seizure. Unable to be formally determined.
\n\u2022 Difficult to determine whether analgesia contributed \u2013 may have caused respiratory depression.
\n\u2022 Formal finding – Respiratory arrest due to depressant effect of opioid medication<\/p>\n
Requirements:
\nUsing the handover you received at the beginning of your shift today, the information below, and Current, reliable evidence for best practice, address the following tasks.
\nDo not make up or assume information about your patient. Only use the information you received today from above handover.
\nResponses should be written in paragraphs. You do not need to include an introduction or conclusion.
\nQuestion 1. Based on the case scenario and using the information from the ISBAR handover only, complete stage 2 (collect cues\/information) and stage 6 (take action) of the Clinical Reasoning Cycle (CRC). (250 words) ( 2 reference apa7 with doi)
\nQuestion 2 Identify three (3) priority nursing assessments that you would conduct at the commencement of your shift. For each assessment you have identified explain the following: (250) words ( 2 reference apa7 with doi)
\n\u00b7 Why is the assessment necessary for the patient\u2019s condition and nursing care? (Ensure you also refer to the underlying pathophysiology around the concerns you discuss)
\n\u00b7 What consequences can occur if this assessment is not completed accurately?
\n\u00b7 What chart or document could you use to Help with\/record your assessments?
\nQuestion 3. Discuss your nursing actions. For each action you take explain the following: (500 words) (3 reference apa7 with doi)
\n\u00b7 The most appropriate course of action to achieve your goals of care.
\n\u00b7 Your nursing diagnoses [at least 3] using current evidenced-based practice.
\n\u00b7 Who is best placed to undertake the required interventions and why.
\n\u00b7 Who should be notified and when if the patient\u2019s condition deteriorates.
\nQuestion 4: short answer responses (1000 words) (10 reference apa 7 with doi)
\nStep 8 of the Clinical Reasoning Cycle requires a nurse to reflect on the process and any new learning that has taken place. These reflections demonstrate how your thinking or assumptions have been challenged, and the deeper insights you have gained. Reflections should be informed by the latest research and professional guidelines.
\nBased on your case scenario and using the information from the ISBAR handover and the shift events, critically reflect on the role and responsibilities of the registered nurse.
\nThe following points must be discussed:
\n\u00b7 Critically analyse pain and medication management in the treatment of your patient, including associated risk management.
\n\u00b7 Consider culturally safe, age-appropriate strategies for promoting health and wellness.
\n\u00b7 Reflect on your role, responsibilities, and scope of practice and refer to legal and ethical frameworks in managing patient care in an acute care setting where appropriate.
\n\u00b7 Illustrate proficiency and understanding of the topic (sample nursing essay examples by the best nursing assignment writing service) by using a minimum of 10 references from academic resources (journals, books, academic or professional websites) from the last 5 years.
\nGuidelines
\n\u00b7 2000 words
\n\u00b7 No introduction or conclusion is required.
\n\u00b7 Use of heading and subheading to structure your writing is recommended
\n\u00b7 Format your assessment with size 12 Arial\/Calibri or similar font, 1.5 spacing.
\n\u00b7 Use APA 7 with doi
\n\u00b7 Write in the third person and avoid the use of -I- and -My-.
\n\u00b7
\nSupplementary resources:<\/p>\n
Australian Commission on Safety and Quality in Health Care Standards https:\/\/www.safetyandquality.gov.au\/standards\/nsqhs-standards
\nNursing and Midwifery Board Professional Standards for Practice.
\nhttps:\/\/www.nursingmidwiferyboard.gov.au\/codes-guidelines-statements\/professional-standards\/registered-nurse-standards-for-practice.aspx
\nNursing and Midwifery Board Professional Code of Conduct
\nhttps:\/\/www.nursingmidwiferyboard.gov.au\/codes-guidelines-statements\/professional-standards.aspx
\nInternational Council of Nurses Code of Ethics for Nurses:
\nhttps:\/\/www.icn.ch\/sites\/default\/files\/inline-files\/2012_ICN_Codeofethicsfornurses_%20eng.pdf
\nView other drafts<\/p>\n
Question 1.<\/p>\n
Based on the case scenario and using the information from the ISBAR handover only, complete stage 2 (collect cues\/information) and stage 6 (take action) of the Clinical Reasoning Cycle (CRC).<\/p>\n
Stage 2: Collect cues\/information<\/p>\n
Patient name: Vanessa Anderson
\nAge: 16 years old
\nSex: Female
\nPresenting complaint: Headache after being hit by a golf ball
\nPast medical history: Asthma, shellfish allergy
\nMedications: Panadeine Forte, Oxycodone, Phenytoin
\nAllergies: Shellfish
\nVital signs: Airway: Own, patent; Breathing: RR 16, O2 Sats 96% on RA; Circulation: HR 62bpm, BP 105\/58 mmHg; Disability: GCS 14\/15; Exposure: Temp 36.2 oC
\nObservations: Intermittently confused, PEARL 3mm, BGL 6.0mmol\/L
\nDiagnosis: Depressed focal right temporal skull fracture
\nTreatment plan: Routine ward assessments and observations, 4\/24 full neuro observations, administer analgesia as prescribed, diet and fluids as tolerated, TED stockings and DVT prophylaxis<\/p>\n
Stage 6: Take action<\/p>\n
Assess the patient’s airway, breathing, circulation, disability, and exposure.
\nObtain a full history of the patient’s present illness, past medical history, medications, and allergies.
\nPerform a physical examination, including a neurological assessment.
\nOrder appropriate diagnostic tests, such as a CT scan of the head.
\nAdminister medications as prescribed.
\nMonitor the patient’s vital signs and neurological status closely.
\nProvide emotional support to the patient and family.<\/p>\n
References<\/p>\n
Australian Commission on Safety and Quality in Health Care. (2016). National safety and quality health service standards. Sydney, NSW: Author.
\nNursing and Midwifery Board of Australia. (2018). Professional standards for practice. Melbourne, VIC: Author.<\/p>\n
Question 2.<\/p>\n
Identify three (3) priority nursing assessments that you would conduct at the commencement of your shift. For each assessment you have identified explain the following:<\/p>\n
Assessment 1: Neurological assessment<\/p>\n
Why is the assessment necessary for the patient\u2019s condition and nursing care?<\/p>\n
A neurological assessment is necessary for the patient\u2019s condition and nursing care because it can help to identify any changes in the patient\u2019s neurological status. These changes can be a sign of a worsening condition or a new problem.<\/p>\n
What consequences can occur if this assessment is not completed accurately?<\/p>\n
If the neurological assessment is not completed accurately, it could lead to a delay in the diagnosis of a new problem or a worsening condition. This could have serious consequences for the patient\u2019s health.<\/p>\n
What chart or document could you use to Help with\/record your assessments?<\/p>\n
The neurological assessment can be recorded in the patient\u2019s medical record. The medical record is a legal document that should be completed accurately and in a timely manner.<\/p>\n
Assessment 2: Pain assessment<\/p>\n
Why is the assessment necessary for the patient\u2019s condition and nursing care?<\/p>\n
A pain assessment is necessary for the patient\u2019s condition and nursing care because it can help to identify the severity of the patient\u2019s pain and the effectiveness of the pain management plan.<\/p>\n
What consequences can occur if this assessment is not completed accurately?<\/p>\n
If the pain assessment is not completed accurately, it could lead to the patient not receiving adequate pain relief. This could have a negative impact on the patient\u2019s physical and emotional well-being.<\/p>\n
What chart or document could you use to Help with\/record your assessments?<\/p>\n
The pain assessment can be recorded in the patient\u2019s medical record. The medical record is a legal document that should be completed accurately and in a timely manner.<\/p>\n
Assessment 3: Fluid balance assessment<\/p>\n
Why is the assessment necessary for the patient\u2019s condition and nursing care?<\/p>\n
A fluid balance assessment is necessary for the patient\u2019s condition and nursing care because it can help to identify any changes in the patient\u2019s fluid status. These changes can be a sign of a worsening condition or a new problem.<\/p>\n
What consequences can occur if this assessment is not completed accurately?<\/p>\n
If the fluid balance assessment is not completed accurately, it could lead to the patient not receiving adequate fluids. This could have serious consequences for the patient\u2019s health.<\/p>\n
What chart or document could you use to Help with\/record your assessments?<\/p>\n
The fluid balance assessment can be recorded in the patient\u2019s medical record. The medical record is a legal document that should be<\/p>\n","protected":false},"excerpt":{"rendered":"
Below case study is real life cases, with some embellishments. Case Scenario \u2013 Vanessa Anderson Shift handover: Identify: Miss Vanessa Anderson, HRN: 123456, DOB: 25\/12\/2004 Situation: Vanessa is a 16yo, healthy active female living in Darwin who was admitted after experiencing a traumatic head injury after being struck on the R) side of her head, […]<\/p>\n","protected":false},"author":5,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10695,10683,10693,10692,10681,10690,10691,10686,10687,10694,10689,7549,10680,10688],"tags":[10553,10549,10616,10615,7687,10254,10627,10247,8857,10552,10295,10548,10622,10551,8907],"class_list":["post-122856","post","type-post","status-publish","format-standard","hentry","category-australia-dissertation-writers","category-bachelor-thesis-writing-service","category-best-dissertation-writers-china","category-best-essay-writing-website","category-cheap-dissertation-help-online","category-cheap-essay-writing-service-us","category-custom-dissertation-writing-services","category-dissertation-assignment-help-uae","category-dissertation-help-tiktok","category-doctoral-dissertation-writing-service","category-thesis-writing-service-sample","category-thesis-writing-writing-help-australia","category-university-dissertation-writing-service","category-write-my-dissertation-usa","tag-1-assignment-help-online-service-for-students-in-the-usa","tag-ai-plagiarism-free-essay-writing-tool","tag-australian-best-tutors","tag-best-trans-tutors","tag-buy-essay-uk","tag-can-someone-write-my-assignment-for-me","tag-cheap-dissertation-writer","tag-help-me-write-my-dissertation","tag-help-with-writing-an-essay","tag-help-write-my-paper-ai-free","tag-homework-for-you","tag-online-essay-writers","tag-phd-essays","tag-write-my-assignment-help-for-college-students","tag-write-my-essay-for-me"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts\/122856","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/users\/5"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/comments?post=122856"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/posts\/122856\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/media?parent=122856"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/categories?post=122856"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/assessments\/wp-json\/wp\/v2\/tags?post=122856"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}