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Case Study Surgical Medical Case Study Essay Example:

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Task 1 – Brief Summery as per question  

Task 2 – Nursing Care Plan:   David Smith

Nursing problem: Acute Pain (Related to:  Tissue inflammation and due to infection.)

Goal of care: Minimise the pain and ensure comfort to David.

Nursing interventions:

• Perform comprehensive assessment of pain using PQRST.
• Determine possible cause of pain or what triggers the pain.
• Provide comfort measures such as back massage, changed position or use of hot or cold compress.
• Administered analgesia for pain as per prescribed.

 

Rationale:

• To determine any changes from previous reports and to rule out the worsening of underlying conditions or developing complications.
• To minimise the pain and possible management that would not further aggravate pain.
• To provide comfort to David and provide non-pharmacological pain management.
• To decrease the pain.

Evaluation:

• David’s pain is control and decrease in intensity using pain scale.
• Using pharmacology and non-pharmacological pain management strategies helps relives David’s pain.
• Giving comfort, relaxed muscle tone and body posture decrease the pain.

 Nursing problem: Risk of fluid imbalance; Related to:  Excessive fluid retention

Goal of care: To manage the fluid intake and output.

Nursing interventions:

• Weight David daily o the same time and with the same clothing.
• Monitor and record fluid intake and output including stools, emesis and IVs antibiotics.
• Provide fluid restrictions for 1200mls fluid intake per day.
• Monitor David’s heart rate, blood pressure and respiratory rate. Inspect the jugular vein.
• Note the colour of urine, urine osmolality and specific gravity.

 

Rationale:

• Weight is best indicator of the fluid status of David. To determine any changes in weight and indicate of fluid retention.
• Assessment can help estimate fluid loss and urine output to determine adequate replacement.

 

• To minimise the fluid intake and prevent from fluid retention and oedema.
• Fluid volume excess can cause increase blood pressure, tachycardia and tachypnoea. Jugular ein may be distended.
• Maintain urine output of 0.5mL/kg/hr and the normal urine osmolality and specific gravity.

 

Evaluation :

Key (if required) for Task 3 &  Task 4

References:

 

NUR251 Assessment 1 Marking Rubric Format and style

Tasks 1, 3 and 4 – Assessing – Patient education- Documentation (15)

Needs development:

Demonstrates a limited knowledge of assessment, documentation and patient education. Does not demonstrate safe practice, knowledge of the relevant assessments and/or explain their relevance to renal function. Unsatisfactory rationales or explanations for care planning and assessments and/ or limited ability to explain and justify nursing actions and education including use of medications. Documentation is not comprehensive and/or does not meet legal requirements. (0 – 5 marks)

Satisfactory:

Demonstrates satisfactory knowledge of assessment, documentation and patient education. Rationales demonstrate satisfactory ability to conduct the relevant assessments and explain their relevance to renal function. Demonstrates a satisfactory ability to provide relevant and comprehensive patient education including use of medications. Documentation is clear, succinct and meets most legal requirements, with errors. (5 – 10 marks)

Excellent :

Demonstrates excellent safe practice knowledge for assessment, documentation and patient education. Explains clearly, succinctly and specifically how to conduct the relevant assessments and explains their relevance to renal function.Demonstrates a high level ability to provide relevant and comprehensive patient education including use of medications. Documentation is clear, succinct and meets legal requirements – (10 – 15 marks)

 

Task 2 – Planning care (15)

Poor interpretation of task or Limited or little ability to develop individualised, comprehensive nursing care relevant to the case study and nursing problem and/or limited to no critical thinking demonstrated in planning and evaluating nursing care. (0 – 5 marks)

Demonstrates satisfactory ability and/or developing critical thinking ability to develop individualised, comprehensive nursing care relevant to the case study and nursing problem, including evaluating nursing care. 8 – 15 nursing actions/interventions identified.  (5 – 10 marks)

Demonstrates high level ability and critical thinking to develop individualised, comprehensive nursing care relevant to the case study, nursing problem, and evaluating nursing care. More than 15 actions/interventions identified.  All interventions are within the scope of the registered (10 – 15 marks)

 

How to write a Best Nursing Case Study Essay Example of Surgery Preparation of Patient David Smith Nursing Assessment Essay- See Below Brief  NUR251  Nursing Assessment question & answers sample