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 evidence-based 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 which is a detailed report of the client’s clinical presentation, nursing diagnosis and inter-professional plan of care. The case report will draw upon your knowledge of pathophysiology, pharmacology 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 pharmacology, and your understanding of this particular client, should underpin the nursing problems that you identify which should, in turn, drive the inter-professional plan of care that is relevant for this clinical scenario.
The case report must include the following:
Introduction (2.5 marks) - 200 words
Using the ISBAR clinical handover framework, introduce the client and provide a brief overview of their case. Provide an outline of the purpose and structure of the report.
Primary medical diagnosis (3.75 marks) - 300 words
Identify the primary medical diagnosis for the client (i.e. Diabetic Retinopathy). Provide a brief description of the pathophysiology of the primary medical diagnosis, with clear links to the case scenario. Support this discussion using current literature (last 10 years).
Medication management (3.75 marks) - 300 words
Identify the current medications prescribed for the client. Provide a brief description of the medications (i.e. mechanism of action, indication, side-effects and precautions). Support this discussion using current literature (last 10 years).
Nursing diagnoses (3.75 marks) - 300 words
(a) Nursing problem related to medical diagnosis:
Using your knowledge of pathophysiology, document one (1) nursing problem that may arise as a result of the client’s primary medical diagnosis. This problem may be an actual or potential nursing problem. Provide a brief description for why this problem may arise for this client. Support this discussion using current literature (last 10 years).
(b) Nursing problem related medication management:
Using your knowledge of pharmacology, document one (1) nursing problem that may arise as a result of the client’s current medications. This problem may be an actual or potential nursing problem. Provide a brief description for why this problem may arise for this client. Support this discussion using current literature (last 10 years).
Nursing Role and Inter-professional Plan of Care (6.25 marks) - 700 words
As the community nurse working as part of the aged care assessment team, discuss how you would facilitate an inter-professional plan of care for this client, with consideration to the two identified nursing diagnoses.
Discuss the aim for and importance of using an inter-professional approach. Discuss the role of the Registered nurse to facilitate the interdisciplinary plan of care for this client. Identify the key members of the inter-professional health care team, and the role that they would play, specific to the two identified nursing diagnoses. Support this discussion using current literature (last 10 years).
Summary (2.5 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 and submitted 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=1144638&chapterid=167259
As the community nurse for the Aged Care Assessment Team, you have been asked to conduct a home visit to assess Mrs Jane Summers.
Mrs Jane Summers is a 64-year-old newly retired office worker, who has recently been diagnosed with diabetic retinopathy and is legally blind in her left eye. Mrs Summers has a medical history which includes type 2 diabetes mellitus (diagnosed five years ago) and hypertension (diagnosed 7 years ago). Mrs Summers' doctor has prescribed Metformin 500mg twice daily and Metoprolol 50mg twice daily.
Mrs Summers lives alone, in her own home. She is a self-described single woman, but has a daughter who lives interstate, and a son who lives locally, both from a previous marriage.
The referral from the General Practitioner (GP) indicates that Mrs Summers has suboptimal blood pressure and diabetes control, despite medication management and recommended dietary control. The last blood pressure recorded was 159mmHg/96mmHg and her glycated haemoglobin (HbA1C) has never been less than 8%.
Mrs Summers lives in a two-story terrace home, with a sunken living room and an outdoor veranda leading to a courtyard garden. The paving on the surrounding brick paths is in poor repair and the garden could do with some maintenance. Several rooms of the home appear cluttered, with ‘keepsakes’ from overseas travels and old magazines stacked in piles around the home.
On general appearance, Mrs Summers appears moderately overweight and has a flushed facial appearance. She wears glasses for reading and driving her motor car and says that she loves to read but has been having trouble recently and describes her vision as ‘patchy and blurred’. On questioning, she does admit to often feeling ‘fuzzy in the head’ if she forgets to take her tablets, but otherwise feels that she is in good general health. Mrs Summers states that she is -doing well- and only retired because she was finding the work on the computer in her job a bit difficult and it was tiring looking at a screen all day, due to her impaired vision. Mrs Summers does not routinely test her blood glucose levels at home as often as she should, and expresses doubt that this would help her, saying: -the doctor knows of my condition, he can sort me out.- Mrs Summers has been trying to lose weight for the past 6 months, without success; but feels that she has more time for exercise now that she is retired, and not stuck behind a desk all day.
Mrs Summers wants to remain in her own home, that she has lived in all her adult life, and takes pride in her cooking, entertaining friends and making her own apple cider. Mrs Summers will require an inter-professional community plan of 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.
Resubmissions will NOT be available for this assessment item