Comprehensive Health Care Assessment: Case Study

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The assignment is 2000 word.

Task aims:
Your task is to explain the nursing care for an adult person experiencing Acute Pulmonary Oedema. In your response you are to include pathophysiology and pharmacological management when explaining the nursing care required. You will refer to an inter-professional model of care inclusive of nursing practice, safety and quality standards.
The course objectives being assessed are;

CO 2. Perform a comprehensive health assessment on adults from a range of different cultures.
CO 3. Apply an evidence-based framework to develop, implement and critically evaluate a plan of care for adults presenting with acute health problems.
CO4. Explain an inter-professional model of care for the management of adults with acute health problems.
CO5. Apply pharmacological knowledge and principles in the management of care for adults with acute health problems.
CO6. Analyse the legal and ethical considerations in caring for adults with acute health problems.
CO7. Apply the principles of quality, safety and risk management in caring for adults presenting with acute health problems.

Task descriptions:
There are two (2) components to this assessment – Part 1 and Part 2
Part 1.
Refer to the case scenario provided in the course site located in the assignment tab for Ms Foley who has been diagnosed with acute pulmonary oedema.
From the assessment information in the scenario, you are to analyse the information provided and then complete two (2) charts – Observation Chart and the HHHS Fluid Balance Chart (FBC). These charts are located on the Learnonline site in the Assessment Folder and are part of your assignment.

In your response to the case scenario presented you are to include a brief description of the implications of your findings from your nursing assessment of the situation. You are then to apply your findings to the relevant pathophysiology of acute pulmonary oedema to account for Ms Foley’s abnormal results.

Explain the nursing care that Ms Foley will require and include evidence based rationales for how you will evaluate the effectiveness of your plan. Include in your explanation the oxygenation requirements, delivery device, and rationales incorporating related pharmacological knowledge for the stat IV 40mg Frusemide order.

Please be advised that the completed chart(s) are NOT included as part of the word count for this assessment item.

Part 2.

Explain the inter-professional model of care required for Ms Foley while in hospital. You are to include the most appropriate national nursing regulatory standards linked to Ms Foley’s care. A starting point is to read the Registered Nurse Standards for Practice (NMBA 2016).

General information:
This assignment must be supported by reference to the course readings and the wider nursing academic literature. For further information refer to Learnonline Assessment Folder for Ms Foley’s case scenario and the marking criteria. Please also refer to the School of Nursing and Midwifery, academic writing requirements located in the Learning and Teaching Resources on course homepage.

 

Case Study

Handover

Ms Martha Foley is a 35 year old lady. It is now day five of admission here in HHHS Ward 1.

Admitted from Emergency department (ED) post multi-trauma of car versus tree at a high speed, she was the passenger and this resulted in:

  • Multiple fractures in both legs from impact
  • Nil loss of consciousness
  • Mild smoke inhalation from being trapped in the car for 15 mins, but no external burn injuries
  • Nil known allergies

Social history

Ms Foley is employed full time at a local supermarket. She is estranged from, and has an apprehended violence order (AVO) out against her former partner. Ms Foley has support from her friends and co-workers who have been in to visit on a regular basis. The driver of the car in the accident was Ms Annie Jones, who is also admitted here in the HHHS. They are good friends and have been providing each other with a lot of mutual support.

  • Current smoker of approximately 10 cigarettes per day
  • Recreational drug use including IV methamphetamines and cocaine (states nil drug use in the past seven days prior to admission).
  • States she does not drink alcohol
  • Vegan

Past medical history

  • Left sided heart failure from congenital heart defect resulting in cardiomyopathy

Ms Foley has required multiple trips to theatre.

  • Day one stabilisation of fractures Ms Foley has a left distal closed transverse tibia and left distal comminuted fibula fractures (ankle)
  • Day three left gamma nail insertion for left neck of femur fracture
  • Today is scheduled for wound wash out of right thigh laceration, and right open reduction and internal fixation (ORIF) of her ankle.

 

Nursing notes

10/08/2017 0515 Nursing note: Medical review overnight at 04.30 by Dr Leon and team. ECG performed. Noted risk of acute pulmonary oedema and is to be managed conservatively at this point. Stat order has been written up to administer 40mgs IV frusemide at 0800. Nil further orders required at this time of entry. [Neurological] Ms Foley is alert and orientated GCS 15, states that she has had a restless night with little sleep. Nil complaints of pain and when asked to rate her pain Ms Foley stated 2/10, declined analgesia. [Breathing] Overnight she developed periods of shortness of breath (SOB) and greater work of breathing (WOB) with her respiratory rate increasing up to 25 Rpm and her O2 saturations dropping to 80% on room air. Orthopnea resolved when she was sat up in high fowlers using four (4) pillows for support with a return of O2 saturations to 95% on room air. [Cardiac] Heart rate sinus rhythm second hourly vital signs at beginning of shift from 1900 to 0300 noted developing trend of hypertension. Began hourly vital sign monitoring now noting a trend towards hypotension with increasing tachycardia. Hourly neurovascular observations of are within normal limits with distal pulse present in both left and right extremities, brisk capillary refill and both feet warm to touch with nil abnormal sensations. Normotensive 36.6 0C. [Gastrointestinal] Ms Foley is currently nil by mouth Bowel sounds present and passing flatus. Bowels not open this shift. [Renal] Ms Foley is using a bed pan passing clear straw coloured urine. Urine assessment NAD. [Wounds] Noted dressings on bilateral legs intact, nil ooze or redness and plaster of Paris intact for left distal leg. Wound site on left hip intact- nil serous exudate ooze or redness. Wound site on right upper thigh has some breakthrough of haemoserous fluid, dressing reinforced- noted patient is for theatre today for a washout of same.[Input] Compound sodium lactate at 200ml/hr via IVC in left distal cubital fossa, site intact nit redness or serous ooze, flushed and patent. [output] noted Ms Foley is in a positive fluid balance. Daily weigh she now weighs 83.5kgs, when five days ago she was at 80kgs [Social] family to be called once she returns from theatre [General] Noted Ms Foley stated she did not sleep well last night and is feeling apprehensive regarding surgery this morning. She went on to say she has ‘bad dreams’ overnight, and has a sensation of suffocating until she sits up [JoH RN Harmon]

10/08/2017 0800 Nursing addendum Theatre nurses have called and are ready for Ms Foley. On attendance she was lying flat on her bed, trying to sit up, and gasping for air. She is apprehensive, stating she is ‘scared’, and that she has a weird feeling that she can only describe as ‘a sense of impending doom’. Vital signs taken and are the following: Pulse 120bpm and regular, BP 100/50, RR 34, SaO2 92% on RA. Her lips have started to turn blue and the nail beds on her fingers are cyanotic. She remains dyspnoeic and desperate for air. She is coughing.

Learning Resources

Textbook(s)  This is some resources which is from the course we need to use that one in the red color   the rest is useful as well .

Berman, A, Snyder, S, Levett-Jones, T, Dwyer, T, Hales, M, Harvey, N, Luxford, Y, Moxham, L 2015, Kozier and Erb’s Fundamentals of Nursing, Volumes 1-3 Australian Edition, 3e, Pearson Australia, NSW.

Lemone P, et al 2014, Medical-Surgical Nursing: Critical Thinking For Person-Centred Care – Volumes 1-3, 2nd Australian Edition, Pearson Australia, Australia.

McIlwraith J & Madden B 2014, Health Care and the Law, 6th Edition, Thomson Reuters, NSW.

Tollefson, J, Hillman, E 2016, Clinical Psychomotor Skills: Assessment Tools for Nursing Students, 6th Ed, Cengage Learning Australia Pty Ltd, Victoria.

Topic 01 Reading 02 – Clinical Nurse Leader–Integrated Care Delivery: An Approach to Organizing Nursing Knowledge Into Practice Models That Promote Interprofessional, Team-Based Care – Bender, Miriam (Bender, Miriam, 2017)

Topic 01 Reading 09 – Cultural safety and continuing competence – Vernon, Rachel (Vernon, Rachel, 2015)
Topic 01 Reading 10 – The cultural safety journey: an Australian nursing context – Best, Odette (Best, Odette, 2014)

Topic 05 Reading 01 – Neurovascular assessment – Judge, Nicola L (Judge, Nicola L, 2007)

Format of writing

  • Use plain fonts such as Arial or Calibri
  • Use a font size of no less than 11
  • Use 1.5 line spacing
  • Set margins at 2.5cm
  • Number the pages

The assignment structure

* Introduction and outline of the assignment

e.g.  what is the purpose of case report

* Completion of clinical assessment tools. observation chart and HHHS FBC (Fluid balance chart)

Analysis and interpretation of all the assessment data

Explain what you find and why/the rational

two (2) nursing assessment forms

Correctly completed, and are present either in the appendix or as a figure,

Analysis of all the findings are provided by a written inclusive summary using the appropriate medical terminology interpreted and uses supporting evidence

Analysis is logical and correct. Is relevant to the scenario Clear, succinct analysis and/or interpretation

* Application of the relevant pathophysiological knowledge to scenario provided

Demonstrates understanding of the pathophysiology by application of theory Application by linking of acute illness event to fluid volume excess with gas exchange impairment leading towards pulmonary oedema by use of appropriate medical terminology and supported by evidence based research. uses supporting evidence and Clear, succinct application of the pathophysiology to the acute illness event

e.g. explain in pathophysiology why this happened and how it is related to past history /

*Discussion of the nursing care you will plan and deliver

for Mrs Foley (an adult with an acute health problem).

Provides a High level and a comprehensive discussion of a nursing care plan Explanation of nursing care to be planned and delivered – the care planned is logical, person centred and relates directly to the scenario and Mrs Foleys’ assessment data.

Includes sound evidence based rationales for care.

Includes how the planned care will be evaluated

We need 3 example here! E.g. reposition the patient up and why we do this because it reduce the work of breathing,

*Explanation of oxygenation requirements, delivery devices and rationales incorporating related pharmacology knowledge for Stat IV 40mg Frusemide order

explain how much oxygen we will give and what type of mask and why

why we give Frusemide what the side effect e.g. low the potassium and this can affect the heart, lowering PB so we need to monitor the PB

what the positive effect of Frusemide

* Explanation of interprofessional model of care required for Ms Foley while in hospital

* Conclusion

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