Word limit: 2000 words
This assessment will consist of a clinical case report. The completed case report will need to be submitted via the Health of Older Adults (NURS 2024) course site Assessment 1: case report link by the assessment due date.
Relevance:
In order to plan and provide optimal person-centred nursing care, Registered Nurses need to be able to interpret clinical information and draw upon their knowledge of pathophysiology and evidencebased clinical practice. Therefore, the purpose of this assessment is to support the development of the skills needed to evaluate evidence and to develop reflection and clinical reasoning skills.
What you need to do:
Based upon the clinical scenario provided below, construct a case report. A case report is a detailed report of the client’s clinical presentation, nursing assessment, nursing diagnosis and nursing management plan. The case report will draw upon your knowledge of pathophysiology and relevant academic literature to support an evidence-based plan of care.
The case report must be presented using the headings provided below. A description of the content for each section of the report has been provided. It is important that all sections of the report are conceptually connected. For example, your knowledge of pathophysiology and your understanding of this particular client should underpin the nursing problems that you identify which should, in turn, drive the nursing management that is relevant for this clinical scenario.
Case Report:
The case report must include the following:
Introduction (1.25 marks) - 200 words
Introduce the client and provide a brief overview of their case. Provide an outline of the purpose and structure of the report.
You might like to think about the overview of the case study like a verbal clinical handover: what is the key information from the case scenario that would be relevant for the plan of care for this client?
Primary admission diagnosis (3.75 marks) - 300 words
Identify the primary diagnosis for the client (i.e. the reason the client was admitted to hospital). Provide a brief description of the pathophysiology and demonstrate how the presenting manifestations support the client’s primary diagnosis. Support this discussion using current literature (last 5 years).
Nursing problems (3.75 marks) - 300 words
Using your knowledge of pathophysiology and the manifestations, identify two (2) nursing problems that arise as a result of the client’s primary diagnosis. These problems may be actual or potential nursing problems. Provide a brief description for why these problems arise for this client. Support this discussion using current literature (last 5 years).
Nursing Management (6.25 marks) - 500 words
The nursing management must focus on the inpatient nursing assessment, nursing interventions and the role of the Registered Nurse (RN) related to medication management for this client and will address the two (2) identified nursing problems. Support this discussion using current literature (last 5 years).
This section of the report focuses on assessments and interventions that the Registered nurse conducts. So, avoid reverting to simple referrals to other members of the health care team - what does the nurse physically do to provide optimal person-centered care as part of the nursing management plan?
Nursing Problem 1: Nursing assessment, nursing intervention, medication management.
Discuss one (1) method of nursing assessment that would need to be performed related to the ongoing nursing management of this nursing problem. Provide a rationale for this type of assessment and briefly describe how this assessment would be conducted in this case.
Discuss one (1) nursing intervention that you would need to implement related to the ongoing nursing management of this nursing problem. Provide a rationale for the intervention.
Discuss the role of the RN in the medication management related to the ongoing nursing management of this nursing problem.
Nursing Problem 2: Nursing assessment, nursing intervention, medication management.
Discuss one (1) method of nursing assessment that would need to be performed related to this nursing problem. Provide a rationale for this type of assessment and briefly describe how this assessment would be conducted in this case.
Discuss one (1) nursing intervention that you would need to implement related to the ongoing nursing management of this nursing problem. Provide a rationale for the intervention.
Discuss the role of the RN in the medication management related to the ongoing nursing management of this nursing problem.
Discharge planning (6.25 marks) - 500 words
The discharge plan must focus on the multidisciplinary management for this client and will address the two (2) identified nursing problems.
Discuss the aim for discharge planning and the importance of using a multidisciplinary approach. Discuss the role of the Registered nurse to facilitate the multidisciplinary discharge plan for this client. Identify the members of the multidisciplinary health care team, and the role that they would play, specific to the two (2) identified nursing problems. Support this discussion using current literature (last 5 years).
Summary (1.25 marks) - 200 words
Summarise the major findings of this case report.
Referencing (1.25 marks)
The content of the case report must be supported through referencing of current literature and must include a reference list and intext citations. You will be assessed on referencing so make sure to follow the UniSA-Harvard referencing style closely to avoid losing marks.
Please refer to the Harvard Referencing System to accurately reference your case report: https://lo.unisa.edu.au/course/view.php?id=3839
Overall writing and presentation (1.25 marks)
This assignment must be saved as a word document. This case report must be structured using the headings provided and presented using academic writing. The use of dot-points will result in a reduction of marks. You will be assessed on the overall writing and presentation, so make sure that you follow the academic writing guidelines closely to avoid losing marks.
Please refer to the UniSA-School of Nursing and Midwifery academic writing guidelines to format your case report: https://lo.unisa.edu.au/mod/book/view.php?id=1478405&chapterid=204134
Clinical Scenario: Mrs Jessica George
Mrs Jessica George is a 79-year-old female living in rural South Australia with her husband of 60 years, Frank. Mrs George was diagnosed with Parkinson’s disease (PD) 15 years ago and she has been admitted to your ward at the Crystal Brook and District Hospital for respite care. Jessica’s mother died of pneumonia at the age of 80, having had PD for 30 years. She has nil other significant medical history. Jessica’s PD symptoms are being managed with Sinemet CR ® (200/50 mg tablets) every four hours during the day and Pramipexole 1.5mg daily. Frank, is her primary carer.
On general appearance, Jessica is alert and oriented but appears slightly anxious with a noticeable tremor in her upper limbs. During the assessment, it is noted that she has a ‘mask-like’ face and speaks in a hoarse, monotonous voice. Jessica’s physical exam reveals a heart rate of 82 with a regular rhythm, normal blood pressure (120/72) without orthostasis and a regular respiratory rate of 16. Jessica is able to arise from a chair without pushing off with her hands. A ‘drag/scuffing’ of the left foot is also noticeable, heard better than seen on ambulation. Her movements are slow and rigid and her balance appears to be unstable but uses no aids. She has had a recent fall at home, sustaining bruising and a skin tear to her left lateral lower leg. She also complains of constipation and a lack of appetite. It is also noted that she starts to cough when given a drink of water.
Frank informs you that Jessica is ‘very particular’ about taking her PD medications ‘on-time’. Jessica believes the effectiveness of her levodopa therapy starts to wear off after 4 hours. Jessica says that she has relatively little ‘good time’ and she alternates between a state of immobility, requiring assistance with activities of daily living (ADL), when the effect of the medication wears ‘off’, and a state of excessive, uncontrolled movements when the medication is in effect.
Jessica is being admitted to the ward for 5 days and will require specific nursing interventions to successfully manage her respite care.
How will I get assistance to complete this assessment?
Each of the topics delivered in this course will provide content that will give you the knowledge that you will need to successfully complete this assessment. For example, the weekly learning activities to develop the ISBAR plan of care will prepare you to complete the case report. You should make sure that you read all information provided, use opportunities to discuss this assessment in the weekly tutorials or virtual classrooms. In addition, the library will run a workshop (via virtual classroom) to support you to identify relevant sources of literature and the course coordinator will run a workshop (via virtual classroom) to support you to plan and write your case report. These workshops will be accessible via the NURS 2024 course site assessment folder.
Case Report Feedback and Results:
Feedback comments and grades will be provided using the Assessment Rubric and grades will be released via the assessment link within 10-15 working days.
Resubmission
Resubmissions will NOT be available for this assessment item.