Medical Surgical Nursing 92438Assessment 3: Case study nursing care plan...

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Medical Surgical Nursing 92438Assessment 3: Case study nursing care plan guidelinesIntent:Objective(s):Weight: Due:Length:Task:The purpose of the assessment is to enable students to apply clinical reasoning and critical thinking to justify appropriate nursing actions and rationales whendeveloping a nursing care plan.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):1.1, 1.2, 1.4, 3.1, 4.3. 5.1, & 5.340%Monday 28th September 2020 by 5pm via the designated assignmentTurnitin portal in UTSOnline for this subject.1500 - 1800 word limit +/- 10%, excluding references (500 – 600 words perNursing Diagnosis)This assessment is the development of a Nursing Care PlanChoose one of the case studies from the tutorial and lab sessions in the Medical SurgicalNursing 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 actions1Medical Surgical Nursing 92438
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.For example: Risk of infection related to skin tear and type 2 diabetes.ReferencingThe Faculty of Health uses the UTS Harvard referencing guide or the American Psychological Association (APA) 7th referencing style for in text referencing and production of a reference list. Please refer to the following links for guidance on these referencing styles: https://www.lib.uts.edu.au/sites/default/files/attachments/page/InteractiveHarvardUTSGui de.pdfhttps://www.lib.uts.edu.au/help/referencing/apa-referencing-guideFurther information: Please note your Coursework Assessment Policy Manual and Student Disclaimer: You are not permitted to use or replicate previous assessment or use this assessment in your future studies.

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Medical Surgical Nursing 92438
Assessment 3: Case Study Nursing Care Plan
Respiratory Case Study – Trent Fulton
	Name of Patient: Trent Fulton 
Name of Case Study: Respiratory Case Study 
Date of Admission: 23/03/2020
	Nursing Diagnosis 1: (Actual) Acute pain due to asthma and pneumonia 
	Goal of Care
	Nursing Actions
	Rationale for Actions
	Evaluation Strategies to Determine Effectiveness of Actions
	The key goal of care with respect to Mr. Trent Fulton nursing diagnosis of acute pain would be to manage the pain in a manner that he is able to perform the activities of daily living without any or with minimal discomfort. 
	The pain assessment should be done based on characteristics like – sharp, constant, stabbing. The changes in character, location, intensity of the pain should be observed. In the work by Beeckmans et al. (2016) it is verified that the respiratory disorders and low back pain have a tendency to be interdependent on each other. Also, if there are any episodes of pain with coughing and breathing, then they should be noted. 
	Though there is chest pain associated with pneumonia, the pain should be regularly assessed. The pain might give an indication of pericarditis or endocarditis. The work by Welch (2017) suggests that pericarditis is associated with inelastic pericardium inhibiting cardiac filling. Through the constant monitoring of the pain it would be possible to prevent the occurrence of any serious infection and treat one in its early stages if found to be existing. 
	The patient should be able to feel relief from pain and the pain scale should stay between 0 to 4 on a scale of 1 to 10. Also, the patient would recover faster and understand the importance of nonpharmacological interventions in management of pain.  It is discussed in the work by Andronis et al. (2016) that the non-pharmacological interventions can take longer to become effective, but they eventually ascertain that there is improvement in the condition without any consequences.
The patient is likely to gain comfort and there will also be no derogatory side-effects in the process od intervention associated with pain. 
	
	It is essential to note down the vital signs of the patients, as they help in assessing the situation in a more refined manner. The vital signs of the patient should be monitored mentioned Gotz (2016).
	The changes in heart rate or blood pressure may indicate pain if all other reasons of change in vitals have been ruled out. Holwerda et al. (2020) have highlighted in their work that the changes in pain intensity have an impact on the blood pressure of the individuals. 
	
	
	The patient should be given certain comfort measures like back rubs, changing positions, massage, etc. so that the patient is able to relax and breathe properly said Joseph (2017). 
	These non-analgesic measures would help the patient to ease the discomfort. Andronis et al. (2016) suggests that the patients feel comfortable when they are not burdened with several different medicines. As the patient is allergic to ibuprofen, these measures would allow the patient to feel independent and give him a sense of well-being. 
	
	Name of Patient: Trent Fulton 
Name of Case Study: Respiratory Case Study 
Date of Admission: 23/03/2020
	Nursing Diagnosis 2: (Actual) Activity Intolerance due to exhaustion of the illness
	Goal of Care
	Nursing Actions
	Rationale for Actions
	Evaluation Strategies to Determine Effectiveness of Actions
	The activity intolerance is associated with the decrease in oxygen levels for the metabolic demands of the body. In the case of pneumonia, the energy reserves of the body also get depleted due to insufficient food intake. Olsson (2020) highlights that it is common to observe immediate exhaustion among patients having some illness, which leads to activity intolerance among them. The patient should be kept as calm and relaxed as possible.

Medical Surgical Nursing 92438Assessment 3: Case study nursing care plan guidelinesIntent:Objective(s):Weight: Due:Length:Task:The purpose of the assessment is to enable students to apply clinical...

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