C ritical thinki ng, reasoning, and eval uation of evidence
('5 marks)
A critical analysis and presentation of the cese study With precise 'irks betwaer the details and care provided aligning with tha principlas of gal liatwe care practice is formulated. An applicable clinical practice guideline ts selected supporting an excellent critique otthe case study provided. Excellent identification of limitations, omissions art/or inaccuraces of care supported by contemporary credible literature and the se ected Clinical practice Guideline. An applicable clinical practice guideline is selected supporting a very good critique of the case Stuey provided Very good identification of limitations. omissions and/or Inaccuracies of care supported by contemporary credible literature and the selected Clinical Practice Guideline on most occasions. An applicable clinical practice guideline is se ected supporting a good critique ottne case study provided. Good identification of limitations, omissions and/or inaccuracies of care supported by some contemporary credible literature and tne seected Clitmcal practice Guideline on some but not all occasvons. An applicable clinical practice guideline is selected supporting a satisfactory critique of the case study. Satisfactory identification of lit-netions, omissions andfor inaccuracies of care are supported by limited credible literature and the selected Clinical Practice Guideline. An inappropriate clinical practice guideline is selected and does not support a critique of the care provided in the case study.
Omissions, limitations and/or inaccuracies are poorly ad dressed Unsatisfactory/ NO Clinical practice guideline is selected. Unsatisfactory critique of tre care provided in the case study Omissions, limitations and-for inaccuracies are not addressed.
Sources and
Reterenci ng
(10 Marks) Credible ane relevant references are used comprehensively.
Accurate use of APA 7 referencing style in all instances. A range of in-text citations has
been used comprenensvely. Crediöle and relevant references are used clearly.
Accurate use of APA 7 referencing style on most occasions. A range of in-text citations has been used cleany. Credible ant relevant references are used sou ndly.
Accurate use of APA 7 referenc ng style on most occasions. A range of in-text citations has been used soundly. Some credible and relevant references are used.
Accurate use of APA 7 referencing style on some occasi ons. There is no variation of in-text citation format. Not all references are credible at-apor relevant
Many inaccuracies with the APA 7 referencing style, NO references
Mechanics
(Grammar, Spelling and Punctuation) (5 Marks) There are no errors with grammar, spelling and punctuation, the meaning IS easily discernible. The critique reads without interru ption. There are minimal errors with grammar, spelling ane punctuation, and the meaning is easily discernible. There are some errors with grammar, spelling and punctuation, and tha meaning is easily discernible. There are some errors with grammar, spelling and punctuation, that impact readability. The meaning is not always discernible. There are substantial errors Witn grammar, spell Ing and punctuation that impact readability. Grammar, spelling and punctuation are such that the reader cannot make sense of the content.

Assessment Critena HD
85-100 D 7584 CR
64-74 54 N 3549 NN
Sequencing:
Sentence and paragraph structure & intelligibility
(15 marks) The content in the critique matcnes the outline presented in the introductory paragraph Organised paragrapns With an excellent progression of ideas. The content flaws from one paragraph to the next on all occasions. The critique enes With a concise, and rational conclusion The content in the critique matches tne outline presented in the introductory paragraph on most occasions. Organisec paragraphs with a very goad progression of ideas. The content flows from one paragrapn to tne next on most occasions. The critique ends with a clear and rational conclusion. The content in the critique matches the outline presented in the introductory paragrapn on some occasions. Some organised paragrapns With a good progression of ideas. The content flaws from one paragrapn to the next on some occasions. The critique ands With a sound conclu Sian. Some content in the critique is in the introductory paragraph. Some organised paragraphs With a satisfactory progression of ideas and content on some occasions, The critique ends With a satisfactory conclusion. Poor or no introductory paragraph,
Content flows poorly from one paragraph to the next. The critique coes not enc with a rational conclusion. Unsatisfactory presentation of ideas. No critique evident.
Knowledge and understanding
(35 marks)
The critique provides a well-articulated understandi of how contem p orary evidenced based theory translatas into practical care. Excellent knowledge of National Palliative Care Stand arts aligned with at least ane of NSQHSS N MBA stenoaras are demonstrated using a palliative approach within the critique. Very good knowledge of National Palliative Care Standards aligned with at least one of NSQHSS and/or NMBA stancarcs are demonstrated using a palliative approach within the critique, Good knowledge of
National Palliative Care Stand arts aligned with at least ane of NSQHSS N MBA stanoaras are demonstrated using a palliative approach within the critique. Satisfactory knowledge of
National Palliative Care Stancarcs aligned with at least one of NSQHSS and/or NM3A standards is demonstrated using a palliative approach within the critique. Poor knowledge
N atonal palliative Care Stantaras aligned With at least one of NSQHSS and/or NMBA standards are demonstrated usng a palliative approach within the critique. Unsatisfactory knowledge of
National
Palliative Care Standards demonstrated, no alignment
NSQHSS and/or NM3A standards.
Appendix B — Criterion Referenced Rubric: Assessment Task 2 Written Critique

References
The list of references utilised in this case study can be used as some of the references for your own critique, however also demonstrate depth and breadth of research by using other sources of EBP also.
ACV Practice guide/ir72v (20/8) Care o/the Dying Patient. Retrieved

Australian Commission on safety and Quality in Health Care. (202'. National Safety and Quality Health Service (NSCHS). Retrieved from: åLtps
aerbasi, S. , Jackson, D_, & East, L_ (2019). Navigating the maze of research : enhancing nursing and midwifery practice (Fifth edition). Elsevier Australia.
Levett-Jones, T. (2018). Learriing to Think Like a Nurse (2nd Ed). Pearson. 2018
Nursing Midwifery Beard of Australia. (2018). Registered Nurse Standards Far Praetjee. Retrieved from state m
Palliative Care Australia. (201 B)_ National Paffiative Care Standards (5th Ed). Retrieved from
Review Critique the given to patient CPG to SOPPdft VSi_f through additional that Highlight the importance of the National Palliative Care Standards and at least afth2 NSQHSS and/or the NMZÅ Standards and hcn.•e they influence our practice
Demonstrate knowledge on the illness trajectory of Motor Neurone Digease (MNü) in line with Palliative Care Principles link'S the Study CPC to identify highlights limitations in
Ensure that your sources are all contemporary (within the last five years) and from evidence based sources) Read all instructions and the rubric very carefu
PLEASE NOTE. YOU DO NOT NEED TO INCLUDE ALL OF TEE POINTS ABOVE IN YOUR ESSAY, THESE ARE GIVEN TO YOU TO ENVOKETHOUGHT PROCESS,

(Borbasi, Jackson, East, 2019)

Clinical Practice Guidelines
CPGls
they?

HOW os to maintain high
DO reflection updating CPC'S thrdi-jgh Case Study
As. described in the Unit Outline you are now required to select an appropriate CPS out of the CPC 'g that have been provided:
The CPC 'G to a Care of the Dying patient
End 01 Life Care
Review Critique the patient against the CPG your Critique thiOLjgh additional that
Highlight the importance of the Natinal Palliative Care Standards and at least one Of the NSQHSS and/or the NM- Standards and how they influence our practice • Demonstrate knowledge on the illness trajectory Motor Neurone Disease CMND) in line with Palliative Care Principles
Provide 'the Study CPG to identify highlights Of fittii'tatibhS in
Ensure that your sources are all contemporary (within the last five years} and from evidence Eased sources) • Read all instructions ane the rubric very carefully
PLEASE NOTE, you DO NOT NEED TO INCLUDE ALL OFTHE POINTS ABOVE IN YOUR ESSAY, THESE ARE GIVEN TO YOU TO ENVOKE THOUGHT PROCESS.

Sys t ernatic reviewL meta-

Reflection

(Levett-Jones, 201 8)
Quality of Life Considerations
Consider some of the following as you select one of the clinical practice guidelines supplied in the assessments folder to assist you with working through the diagnosis, and journey to the palliative care setting:
Rapid diagnosis and dige.ase progression leaves little time to consolidate and prepare for death - spiritual, gacial ane cultural needs must be considered Was an pairi Used?
Haw can the family be provided with support and continuing bereavement fallow-up ?
Consider the adequate ane detailed use af the SAS tool_
Staff provide the patient to aid them in their grief, tb Say gOdåibYé?
Are the National palliative Care standards considered in the CPC?
Were the NM3A and NOHS gtandar8s eengieered in the CPC?
Can 'the CPC to asgiSt its affiliation With töOIg in the palliative getting?
What is your responsibility as an RN to understand the disease trajectory of your patient's. plan their care and the care of their loved one's through the knowledge of nursing standards? Was. the Advanced Health Care Plan followed in the eare that was provided?
Consider these paints and the many others that you may have also thought of as you reflected on the ease Stuey.

RUG-ADL - 17
Short, with respiration rate Of 5. Catherine Sitting by Tyler'S
éktremities took is '-St With

Friday morning — Sunday rnorning
Tyler was visited 3 times per day by the palliative care team. At different times nurses and social workers Visited.
Symptom management included:
Break through intermittent pain relief
Pressure
Oyspnoea relief— intermittent use of CPAP combined with 02 therapy
Mouth careg
Peg
Support and counselling given to Catheiine
Su nday afternoon
When the palliative care nurse visited Tyler, she found him to be restless and agitated. Tyler stated he was in pain, and he just wanted it all to be over. Tyler asked again after his mother and brothers and the chance of being transferred to the hospice. After a thorough assessment, talking to Tyler and Catherine extensively, the nurse implemented the following:
Subcutaneous butterfly (waiting the order far continue-ug analgesia infusion) the hogpiee bed
Peg feeds discontinued
Called Joyce to inform her Tyler's ean8ition
A syringe driver conta ining morphiher haloperidol and onciansetron was eemmeneed after an order was received from the MO.
A hospice bed was arranged for transfer Monday afternoon.
Joyce and Tyler* brothers were making flight arrangementg to be there asap.
MorSi4ie8 KarnafSky Seare - 30
RUG-ADL - 17
Tyler is now in the Terminal Palliative Care Phage
Monday morning
Upon arrival of the palliative eare nurse, Tyler appeared still and comfértable. His Sreathing wag short, shallow and laboured with a respiration rate of 5. Catherine wag sitting by Tylertg bedside_ Tyler's girls were visiting neighbors. Joyce ane Tyler's brothers were due to arrive at Ipm_
At 1025 hrsr Tyler's respiration rate decreased further: upon inspection, Tyler's peripheral extrem ities were cyanosed Tyler'g pupils were and dilated, ane he took is last breath with
Evaluating and Identifying new problems

(Levett-Jones, 201
{Levett•JOn 20181)
Wednesday afternoon
Tyler's peg gite appears to be legg inflamed ane redness has subsidee a little. Tyler remains warm to toue-L RN administered PRN oramorph to aggist with Tyler 8igtregg ane -discomfort. Tyler has. developed a wheeze. Repositioned ta the semi- recumbent position to assigt with breathing. Tyler appeared slightly confused, although wag orientated place, personr ane time. Tyler's mood appears low. He puts a brave {ace an when hig daughters are araund, however Catherine is natieing a significant difference in his deme.anaur.
Thursday morning
Tyler is visited the Palliative Care Registered Nurse. Catherine is eut dropping the Children at gehoe-l_ Tyler appears to be extremely short breath ane struggling to breathe. 02 2L via NP wag insitu_ The RN applied NIV to assist Tyler with his breathing.
Thu•sday afternoon
V,åhlen attending to Tyler's personal cares, Tyler made some requests te the RN. He agke8 for the CPAP machine to be removed, more analgesia for his increased pain and discomfort, he requested {or arrangementg to be made a bee in the hospice ane requested for his mother and brothers to be contacted. The RN spoke with C.atherine regarding contacting Tyler's extended family. Time was spent with Catherine talking about Tyler's eon8ition at present_ Tyler was orientated to pergonr place ane time.
Catherine did net want to share this time with Jayce and Tyler's brothers and thereiare did not contact them.

Establishing Goals and Taking Action

(Levett-Jones. 201 8)

(Lovett-Jones. 2018)
Wednesday afternoon

National Palliative Care ?
NSQHS Standards? NM8A Standards?
about trajectory Of motor
How will I recall information previously learnt and understood about this illness?
Where are geme 01 the best locations to aecesg EXP ane current standards of care? ig in supporting the patient their What is a SAS Tool?
What ig the Problems Severity Score/ (PSS) ig Mcjéi4iee Score?
What is a RUG-AOL score?
How do I determine the Palliative Care Phage that the patient is in?
DO I to Start difficult conversations patient their Supports 'Aha t about prognosis? What are same af the complications that the patient and family may face?
Are there any specifie symptoms that should be looking for when developing a care plan?
ig the dies the 'this patient? What should I expect?
Am ready to deal with this?
60 1 get RN if I
Have I thought enough about my own well being and resilience for this professional specialty?
How do I eare for a deceased person? H ow W ill I what to gay?

Identifying problems/issues

Considerations for the Community palli a Care Setting
af these a re continuously being assesed
Falls Risk Assessment

Pain Assessment
NOK contact details
Health Care Directive Modified Karnofsky Score of 3040
RUG. AOL 17
SAS TOO' C
might be need to his family
National Palliative Care Standards ?
NSQHS Standardg?
NM3A Stand arc'S?
What do I know about the illness trajectory of motor neurone disease?
How will [ recall inferr•nation previously learnt ane understood about this illness?
Some Of best E3P Current •tare?

•Overall decline in patient's condition on osservatier•L Physically dependent for all activities of daily living. -
MOüiCdI
mitriptyline Smg N octe i alarrhea
Multivitamin Suspension mis OD
Febrile
phalothin n fection
Metronidazele n feetien

ramorph 5mg 4/24 ain' Discomfort
_ N Otte
Microlax Enema 1 tube an ipation
•Patient appears to be orientated to person, place and time. Some confusion at times, most likely due to infection present. -
Patient'S Wife Of patient his t is my that the patient'S Wife is recovery Current infec'tidfi_ Rig understanding of the patients condition. -
Pa illative Care phage

lar Medications ication
lazepam Smg Noete nxiety
MS Contiri S•.jgpensidth
Movicol Sachet onstipation
mitriptyline 5mg Natte ialc,rrhea
Multivitamin SUGPéhGidttI
Processing Information

Review of Medical Officer from Palliative Care Community Service
The f'nedieai (MO) by Registered peg Site infection. It With Tyler the IV antibiotieg_ MO suggested admission ta hospital for treatment, hcnxever Tyler was not keen on this suggestion. After discussing hospital admission with both Tyler and Catherine together, it was decided that this wag not an option_ The Community Palliative Care Team provide further care to Tyler with provision of 'VAB 'g in the home. It was arranged for Tyler to have a day vigit to the hospital insertion Of PICC to Of antibiotics.
Post review Medical Officer from Palliative Care Community Services:

lar MedicatiQ ns ndication
ù iazepzm 5mg Noete nRiety
MS Cdthtir. Suspe•ngiOth
Movicol 1 Sachet on stipation
mitriptyline 5mg Noete ialarrhea
Miaitiüiterriir. SLjgpengiOth
Paracetamol lg
'amorph 5mg 4/24 ain/ Discomfort
10 na dine _ 'mg Noete ialarrhea
I tube O St (patidri

1900 hrs
RR: 26
BP: 120/70
SaC2 92% on 2Lmin NP
GCS: 14/15
lar Ededications ication
NO Cte
MS Contin Suspension Controlled Release mg
Movieol 1 Sachet 80 onstipation
mitriptyiiae Srrig NO ete
Multivitamin Suspension
Paraeetamol 1 OID
Temp: 39.2 degrees
Patient Notes from Community Nurses over 24-hour Period:
-Patient's mobility has decreased. He is now spending more time in bed secondary to weakness in arms and legs. Increased requirement of care from 1 person to 2 people to transfer patient. Patient appears more SOB. 02 therapy and NV continues. Peg feeds continuing as per regimen. Patient's mood appears low. Friends in attendance during visit. Patient communicating in short bursts.-
-Patient RI' during visit. Patient's position altered. Patient sleeping for most of nursing Visit. Patient appears more fatigued. Extra analgesia administered as per patients request. Peg feeds continue as per regimen. Wife and youngest child in attendance during visit, Patient appears warm to touch. Fan applied to assist with climate control.-
-Patient appears very drowsy throughout visit. Patient appears flushed in the face and remains warm to touch. Peg feed disconnected as per regimen. Peg site appears red and inflamed.
Swab taken fram Peg site for pathology. Patient appears in discomfort Paracetarnol lgrarn given via peg. Orarnorph 5mg given via PEG. NIV connected. Patient repositioned in bed.
Patient's wife was attending to children during nursing visit. Wife reports spending mare time sleeping throughout the day. Voice message left for doctor review mane. -
Dyspha gia Law mood

Foot drop left foot
Increase demand for N IV
02 Therapy Peg Feeds
Intermittent in4éetiong Peg site
Gathering new Informati
Tyler'g •vital signs when visited by the Palliative Care Nurse:
0900 hrs
24
HR: 80
120/70
Sa02: 2Lmin NP
14/15
Temp: 38 2 degrees
1300 hrs
24
HR: 70
120/70 Sa02: 2Lmin NP
ccs: 14/15 Temp: 388 degrees
1900 hrs

Collect Cues and Information

(Levett-Jones ZJI
past Medial
R) Wrist as. a child
• Agth
Current
• Weakness in left and right hands
• Increase in ciysponea on exertion and at rest

Headaches
Dygphag ia
LOW
Constipation

12 ago
Around 6 months after initial symptoms and 3 months after diagnosis, Tyler's condition had deteriorated. Tyler now required a walking frame to mobilise. His dyspnoea has increased, he was suffering from headaches and was generally fatigued Tyler was being assessed by a respiratory specialist for the requirement of Non-invasive ventilation especially at night. Tyler naw suffers from dysphagia and was being assessed in consultation with the respiratory specialist and dietician the need far a gastrostomy.
ago
Tyler's condition has continued to deteriorate. Due to insufficient nutritional intake secondary to dysphasia, Tyler had a gastrostorny inserted. Since insertion, he has had infections at the insertion site. Tyler also requires assistance of NIV mainly at night, however the demand has increased significantly over the last couple of weeks. Tyler's mobility is limited. He walks intermittently with the use of an aid and one person. His mobility is limited due to progressive foot drop and increased dyspnoea. With his condition worsening, Tyler initiated the difficult conversation with Catherine about his mortality. Catherine is still not accepting of Tyleds condition nar is she wanting the Children to know the extent of Tyler's condition. Tyler completed an Advanced Health Care Directive and he ensured bath Catherine and his mother Joyce had a copy. Tyler is currently visited weekly by the Community Palliative Care Team and he has daily support from Community nurse to assist with his activities of daily living.
Despite Tylerrs progressive physical deterioration and the ongoing tensions with Catherine's inability to accept his condition. Tyler values the time he gets to spend with his 3 girls. Watching them play together and their interactions are invaluable to Tyler. Tyler has insisted that his mother and brothers are able to visit monthly. When his family visit, Catherine generally takes the girls and leaves Tyler at home. Although this an ideal situation, Tyler has come to accept the conflict between Catherine and Jayce. Tyler is also still in contact with his colleagues fram the Aidarce who visit him freq uently.

Consider the Patient Situation

The
Andrea (8 Y—ars)
Jessie* (5
Erin (2
a b- time togethet•. With his thig lot Of
After in his 'bit
L'poth diaghOSig, téh±idri With 'the relatiOriShip
Aetiology of Motor Neurone Disease
Motor neuron disease (MND) is a progregsi•.'e neurological disorder eharaeteriseci by logs 01 motor neurons (Brownv Edwards, 3uekley & Aitken, 2017). There are 4 main types of MND, depending the level of motor neurone involvement ane where symptoms begin. These include:
Amyotrophic: lateral sclerosis (ALS) Progressive bulbar palsy CP8P)
Progressive muscular atrophy (PMA)
Primary lateral sclerosis (PIS)
VIND usually leads to death 20-48 months after symptamg begin, however 5%- patients may gurvive for more than 10 years (MND New Zealand, 20181 The onset MND ig usually betv.•een 40 ane 70 years of age and ig more common in men than women by a ratio of (MNO Australia, 2018). The prevalence is appr0Rimately 8.7 in 100 000 in Australia (MND Australi@,
2018b
Motor neurong in the brainstem anci the spinal eard gradually degenerate. Dead motor neurang cannot produce or transport signalg to museleg_ Consequently, electrical anci chemical messages originating in the brain 80 not reach the muscles to activate them. The typical symptoms far diagnosis MND are limb weakness, eysarthria and dysphagia (Brown et al_, 2017b Muscle wasting and fasciculations results 'ram the -dener•uation of the muscles ane lack of stimulation ane use. Other symptoms include pain, gleep disorders, spastieity, drooling, emotional liability, depressionr constipation and zesophageal reflux (Brown et al 201 7)_ Death usually results from respiratory tract infection secondary to comprised respiratory function.
Throughout the illness trajectory for MND, the patient remains cognitively intact while physically declining. The patient should be encouraged to partake in moderate ihtensity, endurance type exercise for the truck and limbs ag this may help reduce MND spastieity.
Nursing interventions include but are not limited to (3rown et al_, 2017):
Facilitating eemmunieation
Reduéing risk af agpiration
Facilitating early identification of respiratory insufficiency
Deereaging pain secondary to muscle weakness
Deereaging risk injury related ta falls
Providing diversional activities such as reading anci companionship

Haw do I relate standards to the ease study?
This is where your critical thinking and application theory to practice ig requiredr we cannot tell yau how to this, as a final year nursing unit it ig essential that you are aware of hew all these standards, uphold ane maintain, patient eentree care, dignity, patient assessment and safety to name a few Spend some time reviewing these anci map out the ones that yau believe are important for your critique.
Students are required to demonstrate an understanding ef how theory translates inte prattieal nursing care and how evidence underpins best practice. Each student will review and critique the eare given in the Cage Stuey provided according to their ehaiee of ONLYONEaf the provided Clinical Practice Guidelines (CPC's) best suited to the highlighted discussion,
Where fid the CES thatyou Bent me to use?
You are provided with CPC's for this task, in this booklet .
You need to ehaoge one 04these only to demonstrate the area of eare that you are providing a critique of_ You are not expected to leak for other CPG's to support your work, however evidence based praetiee 01 peer reviewed journal publications are expected to further reinforce the eritigue_
Learning outcomes LOI L05, LC7
Haw to s,Lbmit: Electronic Submiggion •via Turnitin
Return Of assig•vment: The asgesgment feedback and grade will be returned via Turnitin_
Assessmentcriteria: The asseggment will be marked using the criteria-based rubric. Please note that in-tent citations are included in the we-re count whilst the reference list ig not ineluee8 in the ward count. Words that are more than 10% aver the word count will not he considered
- ear, be found in the unit outline in Appendix 8

are to que 'Zing only
TO complete task you will need to and critique relevant elements Of the CPG and case study whilst upholding the National Palliative Care Standards at least one Of:
- NSQHS
- NMBA standards and/or
FAQs
As the rubric states if you provide Outstanding knowledge of themes and principles associated with palliative care this will demonstrate an outstanding application of your knowledge to praetiee therefore using Stan-dares 'ram mere than one of the above ane relating them together to uphold your critique of the patient eare and support the clinical practice guideline
Using not provide Strong application However, a Of multiple standards that as registered nurses we are required to uphold will absolutely demonstrate very strong knowledge and understanding, if you link them together well with evidence based practice (E8P)
Where do find Of standards?
You should be aware of all 04 the standards above ag they have been discussed in many units throughout your degree, so now it ig time to demonstrate your knowledge and bring them together. to aggist you We have provided linkg below to each of the standards we would like to utilise in your critique.
Eight National safety and Quality Health Service Standards to provide a nationally consistent level of eare that can be expected by all eonsumers from all health organisatiens

Seven Standards that all Registered nurgeg must uphold to ensure that they maintain their registration anci provide pergan eentred and evidence based preventative, curative, supportive, formative and palliative elements to their praetiee

Nationa,/ Palliative Care Standards
Nine National palliative Care gtandar8s that you knew well ag they have Formed the framework of NRSG374 and were fundamental for assessment task 1 standards to the case study?