This written assessment asks students to use the clinical reasoning process and refer to evidence based practice to formulate a nursing plan of care for a specific patient experience case analysis...

This written assessment asks students to use the clinical reasoning process and refer to evidence based practice to formulate a nursing plan of care for a specific patient experience case analysis  (see: “Case Studies for Written Case Analysis Report”). After reflecting upon, analysing and researching the information provided in the case study, students will address each of the following tasks:
1.    Critically analyse the patient assessment findings, taking into consideration the person’s situation and medical diagnosis. Discuss the data/information collected and priortise that information in terms of relevance to their nursing care using DRABC.  (10 marks)

2.    Identify three (3) nursing priorites for this person;
•    One of which must address the client’s psycho-social needs.
•    The nursing priorities must be discussed in order of priority (e.g.: what nursing diagnosis should be addressed first and why).
•    You must also establish one patient centred goal for each nursing priority (supported by evidence).  (5 marks)
3.    For each nursing priority, discuss the specific nursing interventions (what you would do and why) that would be appropriate. Each intervention must include detailed rationale (why you did what you did) and specific evaluation criteria (how will you know if the intervention was successful). Your nursing interventions must be person or family centred and must be specific to this client (e.g., tailor the intervention to meet the needs of this specific patient based on evidence and professional recommendations). All interventions must be referenced from professional literature.  (20 marks). The quality of your academic writing will be assessed throughout each of these three sections and will contribute to your overall mark for that section. Please see 6h for specific guidelines for formatting an academic paper. Additional marks will be awarded for using correct APA format and referencing throughout your paper (5 marks). (reference should be 10 -15 )


9049 Assessment 2, Case One, Page 1


You are a student nurse assigned to a afternoon shift in the emergency department of an acute
care facility. Please  complete your written patient experience case analysis report using the information provided below (see Moodle site,
“Unit Assessments” for the marking rubric). This is due no later than: 2355 Friday 7th May.
Case Study 1


You are caring for Ms. April Wednesday who has been admitted to the acute care area of ED.
Presenting History
April is a 32 year old woman who presents to the ED with shortness of breath that she states
has developed over the past two days. She has been feeling a bit dizzy this morning and
thought she should see a doctor as she developed what she describes as very mild chest pain,
mostly on inspiration, this morning. She also reports her calves are sore and a little swollen.
She initially called a medical advice line who suggested she attend an emergency department
rather than a general practitioner (GP) clinic. From your observations, it is clear April is using
accessory muscles to breaths in and she reports that she has been using a lot of extra effort.
Medical History
April reports she is normally fit and healthy. She has reported she has an allergy to penicillin.
April’s only past history involves sporting injuries. Her only medication is an oral contraceptive
that combines 30 micrograms of ethinylestradiol with levonorgestrel. She travelled to Thailand
on a work trip, returning the day before the symptoms appeared.
Social History:
April is an engineer. She has a partner, Jason who is in the waiting room. Jason has one child
and is a ‘stay at home’ dad.
As the nurse in the ED you conduct a full examination of April. Her vital signs are currently:
BP: 104/ 74 mm Hg
HR: 105 beats/ minute
RR: 28 breaths / minute
Temp: 37.2 OC
SpO2: 91% with no supplementary oxygen.
You apply a simple face mask with 10 l/min of supplemental oxygen in response to the low
SpO2. As April has chest pain and is tachycardic, you perform an electrocardiogram (ECG),
which shows normal sinus rhythm and a prominent S wave in lead 1 and a Q wave and
inverted T wave in Lead III (S1Q3T3 pattern). Blood tests are taken for urea and electrolytes,
full blood examination, cardiac enzymes and d-dimer. A chest x-ray has been arranged.
Aprils chest x-ray shows good air entry and lung expansion, with some congestion around the
pulmonary hilum. There are small scattered opaque marks through the lung fields. She reports
that she is finding it easier to breaths with the supplemental oxygen.
The medical team have ordered glyceryl trinitrate (GTN) for the chest pain, which was given 10
minutes ago. April reports that it still hurts to breathe as much as it did before. The blood test
results show normal ranges of cardiac enzymes and a raised d-dimer.
9049 Assessment 2, Case Two, Page 2
April’s vital signs are now:
BP: 94/ 72 mm Hg
HR: 112 beats/ minute
RR: 28 breaths / minute
Temp: 37. O C
SpO2: 93% with 10 l/min of supplemental oxygen via a simple face mask.
April’s chest x-ray indicate several pulmonary embolus (PE’s) are present and the clinical
features of dyspnoea and hypotension motivate medical staff to actively treat her condition.
April is given a bolus dose of heparin and a continuous infusion is prepared. April is placed on
continuous monitoring of ECG and SpO2. Further blood tests are taken for arterial blood gas
(ABG) analysis to determine the extent of April’s hypo-perfusion and potential lactic acidosis.
Please formulate a plan of care for April following the Assessment 2 Guidelines and marking
rubric.