Nursing Assessment, need to develop a clinical reasoning ,
3/9/2020 template https://mylo.utas.edu.au/d2l/le/content/347842/viewContent/3279960/View 1/5 Print/Download this page Template for your assessment submission Preparing to complete your assessment submission: You will use a template to structure your submission. When you download it, save it as 'youridnumberT2253' (e.g. 111111T253). Type your responses into the allocated area in the template. Make sure you save your work often. As you type in the allocated areas, the 'boxes' in the template will expand to fit your content. Download your answer template here: CNA253 Gwen Boren Template.docx Download the marking rubric here: AT2 Rubric.pdf To download a .pdf version of this entire page - select 'pdf version' in the page banner. Assignment Presentation: 1. Use ONLY the template provided. Do not change any of the headings or template structure. 2. Use 1.5 spacing in the following sections: Relate and Infer, Predict and Diagnoses. 3. DO NOT use direct quotes. 4. Ensure that you reference correctly according to the UTas Harvard Guide for Nursing, found here. https://utas.libguides.com/c.php?g=693909&p=5790285#s-lg-box-18364645 Can your marker EASILY find the source that you have used? If you provide a link, does the link work? 5. Ensure that each entry in your reference list is separated by a paragraph space. Now you are ready to start! Consider the Patient Situation Gwen Boren Mrs Gwen Boren (80yo) is a pa�ent on your ward. You receive handover at the start of an early shi�. “Mrs Boren lives at Sunnivale Nursing Home. At about 0200 this morning, she was found on the floor. The report from the home states that she wasn’t able to explain what happened, and she was rather confused. She was brought in by ambulance. Mrs Boren has a history of a cerebrovascular accident with mild right sided physical deficit, but no cogni�ve impairment. She also is managed for atrial fibrilla�on. She uses a walking frame to get around. She had a head CT which noted no further changes.” https://mylo.utas.edu.au/content/enforced/347842-AW_CSN_20S1_22152_0_0_0_1_1/2020%20Sem%201/Assessment%20Task%202%20CNA253/Gwen%20Boren/CNA253%20Gwen%20Boren%20Template.docx?_&d2lSessionVal=9k5HeNuDqieufeQBRUlFpRgvf&ou=347842 https://mylo.utas.edu.au/content/enforced/347842-AW_CSN_20S1_22152_0_0_0_1_1/2020%20Sem%201/Assessment%20Task%202%20CNA253/AT2%20Rubric%20Sem%201%202020%20For%20Students.pdf?_&d2lSessionVal=9k5HeNuDqieufeQBRUlFpRgvf&ou=347842 https://utas.libguides.com/c.php?g=693909&p=5790285#s-lg-box-18364645 3/9/2020 template https://mylo.utas.edu.au/d2l/le/content/347842/viewContent/3279960/View 2/5 putCaptionHere “An x-ray of her le� ankle showed a fracture. A plaster back slab has been applied, with the bandage that you can see here.” “She has had paracetamol and sub cut morphine, which have been effec�ve. We have been doing hourly vitals, neurological and neurovascular observa�ons. The early confusion has resolved. She has only just arrived on the ward.” You proceed to provide care for Mrs Boren. It is now 0830, you take her regular medica�ons to her and she says, “Where am I dear? Could you help me, my leg is hur�ng badly?” You undertake observations. Collect Cues - Review the documentation available to you Review the existing documentation for Gwen Boren (these will open in a separate window, or download to your download folder, depending on your browser): GWEN BOREN ADDS Chart.pdf GWEN BOREN Medication Chart.pdf GWEN BOREN Neurological Obs.pdf GWEN BOREN Neurovascular Lower Limb.pdf GWEN BOREN Patient progress notes.pdf GWEN BOREN CT Report.pdf Collect Cues - Gathering further information You undertake additional assessments at 0830, to gather new information, recording the following data: Vital signs: BP: 170/95 mmHg Pulse: 108 bpm RR: 21 Sp02: 99% Temp: 37.5C Other data: Neurological Assessment: Best Eye Response: 4 Best Verbal Response: 4 Best Motor Response: 6 Pupils: R) 3+ L) 3+ Limb movements: Arms – le�) normal power, right) mild weakness; Legs (R limb only) – mild weakness Neurovascular Assessment: Left toes Colour: blanched Warmth: cool Pulses: not accessible Movement: wiggling toes – A+ and pa�ent is reluctant Sensa�on: pins and needles in all areas Swelling: cannot assess https://mylo.utas.edu.au/content/enforced/347842-AW_CSN_20S1_22152_0_0_0_1_1/2020%20Sem%201/Assessment%20Task%202%20CNA253/Gwen%20Boren/BOREN%20ADDS%20Chart.pdf?_&d2lSessionVal=9k5HeNuDqieufeQBRUlFpRgvf&ou=347842 https://mylo.utas.edu.au/content/enforced/347842-AW_CSN_20S1_22152_0_0_0_1_1/2020%20Sem%201/Assessment%20Task%202%20CNA253/Gwen%20Boren/BOREN%20Medication%20Chart.pdf?_&d2lSessionVal=9k5HeNuDqieufeQBRUlFpRgvf&ou=347842 https://mylo.utas.edu.au/content/enforced/347842-AW_CSN_20S1_22152_0_0_0_1_1/2020%20Sem%201/Assessment%20Task%202%20CNA253/Gwen%20Boren/BOREN%20Neurological%20Obs.pdf?_&d2lSessionVal=9k5HeNuDqieufeQBRUlFpRgvf&ou=347842 https://mylo.utas.edu.au/content/enforced/347842-AW_CSN_20S1_22152_0_0_0_1_1/2020%20Sem%201/Assessment%20Task%202%20CNA253/Gwen%20Boren/BOREN%20Neurovascular%20Lower%20Limb.pdf?_&d2lSessionVal=9k5HeNuDqieufeQBRUlFpRgvf&ou=347842 https://mylo.utas.edu.au/content/enforced/347842-AW_CSN_20S1_22152_0_0_0_1_1/2020%20Sem%201/Assessment%20Task%202%20CNA253/Gwen%20Boren/BOREN%20Patient%20progress%20notes.pdf?_&d2lSessionVal=9k5HeNuDqieufeQBRUlFpRgvf&ou=347842 https://mylo.utas.edu.au/content/enforced/347842-AW_CSN_20S1_22152_0_0_0_1_1/2020%20Sem%201/Assessment%20Task%202%20CNA253/Gwen%20Boren/Gwen%20Boren%20CT%20Report.pdf?_&d2lSessionVal=9k5HeNuDqieufeQBRUlFpRgvf&ou=347842 3/9/2020 template https://mylo.utas.edu.au/d2l/le/content/347842/viewContent/3279960/View 3/5 Blood loss: nil Pain: 10/10 Capillary refill: 5 seconds Next step in the assessment task Before you continue with this assignment you should recall and apply your existing knowledge to the above situation to ensure you have a broad understanding of what is/may be occurring. When you have done so, you will be ready to document your information processing in the template that you downloaded, following the following steps 1-5 below. 1. Process Information - Interpret In your downloaded and saved submission template list the data that you consider to be normal/abnormal in the area provided. Ensure that you provide normal reference ranges for abnormal data, and a citation for your source. An example is provided here: Normal (Subjective & Objective) Abnormal (Subjective & Objective) GCS 15 BP155/90 2. Process Information - Relate and Infer Relate: cluster clues by identifying relationships between them. Infer: make deductions as to why a cue, or a cluster of cues may be considered abnormal in this context. Justify by referring to the relevant anatomy, physiological mechanisms and pathophysiology. Based on your interpretation of all the information/cues presented, form and justify an overall opinion on what may be happening. Document this in your downloaded (from the link above) and saved template. (550 word limit) 3. Process Information - Predict In your template Explain what may happen to your patent if no action is taken. (150 word limit) Next steps in the Assessment Task - Identifying the problem(s) and developing diagnoses, Establishing Goals, Taking Evidence-based Actions, Evaluating Outcomes. Based on your understanding of your patient's current situation you must now: develop, articulate and prioritise at least three (3) nursing diagnoses. for each of your two (2) highest priority nursing diagnoses establish one (1) goal/desired outcome. list 2 - 3 related actions you would undertake to achieve that goal provide a rationale that demonstrates that your actions are evidence-based. Support your rationale with evidence from the literature. 3/9/2020 template https://mylo.utas.edu.au/d2l/le/content/347842/viewContent/3279960/View 4/5 describe how you would evaluate the effectiveness of the care provided (i.e. how will you know that your actions were beneficial to the patient) 4. Identifying problems, taking action, and evaluating outcomes In your template an area is provided for you to list nursing diagnoses that you identify. You MUST list at least three (3) diagnoses in order of priority (not included in word count). a table is provided for you to document and justify the care you plan to provide for Mrs Gwen Boren. Only the two (2) highest priority diagnoses should be addressed. (550 word limit) This is not the template, it is an illustration only. Download the template from the link provided in the green box at the top of this page) Diagnosis 1 Goal/Desired outcome/s Related actions Rationale Evaluate outcomes DO NOT REWRITE THE DIAGNOSIS
>>>> Diagnosis 2 Goal/Desired outcome/s Related actions Rationale Evaluate outcomes DO NOT REWRITE THE DIAGNOSIS>>>> Final checks before you submit 1. Make sure you have added your student ID number to the template (top left hand). 2. Have you completed all sections of the template? 3. Have your prioritised the nursing diagnoses? 4. Have you included only the top 2 in your discussion table? 5. Have you REFERENCED in-text, all assertions, guidelines that you have used, protocols, reference ranges, professional standards and anything else in your submission that has come from another source? Are your sources contemporary (not more than 10 years old, journals should be no more than 5 years old, have you checked that you are referring to the LATEST guidelines )? 6. Are all of your in-text references in your reference list? Are all of your reference list entries used in-text? 7. Have you proofread your document? have you read your assignment out-loud? How's your English expression and are there any typos? 8. Have you checked your work against the assignment presentation requirements at the top of the page? All done? Time to submit. 5. Submitting 3/9/2020 template https://mylo.utas.edu.au/d2l/le/content/347842/viewContent/3279960/View 5/5 Once you have carried out your final checks - Choose 'Assessments' from the taskbar Choose Assignments Choose CNA253 Assessment Task 2 Check that your MSWord template is correctly named e.g. youridT2253.docx Upload your submission. Relax. All done! Template provided by the Digital Innovation Team (mailto:[email protected]) mailto:[email protected]