NCP106 Nursing care plans

Assessment 1, Part B: - CASE STUDY RESPONSE TEMPLATE

Student Name

Date

Course

HLT54115 Diploma of Nursing

Subject Code and Title

NCP106 Nursing care plans

Unit(s) of Competency

HLTENN004 Implement, monitor and evaluate nursing care plans

Performance criteria, Knowledge evidence and Performance assessed

PC; 2.7, 2.8,3.1,3.2, 3.3, 4.1, 4.2, 4.3, 4.4

PE:1, 3, 4

KE:4,5, 8

Title of Assessment Task

Assessment 1, Part B: Case Study

Type of Assessment Task

Short Response

Length

As indicated for each question

Submission

Due by the end of Module 5.1 (Week 9)

Question 1 ;(100 -150 words)

On Sunday at 13:42hrs, you are about to leave to have your lunch break when Mr McFarlane's wife calls you from the corridor and states “Nurse! My husband does not look well and something is wrong with him. Please can you come and have a look at him?” On entry to Mr McFarlane's room, you notice the following:

•He is lying in a supine position

•His breathing is short and shallow

•Pale and clammy skin with slight cyanosis around his lips and peripheral extremities

•His eyes are closed and not opening when you call his name; eyes open with trapezius squeeze (painful stimuli), and the best motor response is localising.

Discuss the nursing actions you will take to manage this situation, with rationales for your decisions, including referrals.

Reference required

Response:

Actions

Rationale

1 Performed CPR

2 Placed ECG leads

3 Inserted IV cannula

4 Checked pulses

5 Applied defibrillation pads

CPR is given as patient is found with slow and shallow breathing.

There is a need to place ECG leads as patient is experiencing irregular heartbeats and breathlessness and dizziness.

IV cannula is inserted to provide oxygen as he is ;found breathless.

It is very important to check the pulses at short interval of time as it helps to evaluate if patient has reached ROSC.

Defibrillation pads are required as patient's heartbeat is irregular. It would help patient to maintain a normal rhythum.

Question 2: (100 words)

You have taken a set of vital signs and get the following findings:

RR: 9/min, SpO_2:;;74% Room Air, BP: 100/60mmHg, HR: 45/min and irregular, Temp: 38.7^OC, BGL 2.5 mmol/L

a);Document the findings (consider data from Q1 and Q2) on the charts used in Assessment 1 part A (Observation and GCS charts ONLY. These charts MUST be uploaded as a part of your submission)

b);Analyse the patient's condition based on the information in Q1 and Q2 and discuss your concerns about the patient (You may use the systematic approach to assessment - ABCDEFGH approach).

Reference required

Response (to part b)

Ans:- Patient's SpO2 level was observed as 74 percent which is below the normal range. Hypoxemia is a condition where the level of SpO2 in blood falls down due to sleep apnea, high-altitude exposure and cardiopulmonary complications. It might be possible that patient has administered certain medication which caused hypoxemia. ;Blood pressure of the patient seems to be fluctuated down in medical reports. It indicates that patient must be dehydrated. Specific medical conditions also induce lower blood pressure. Further assessment is required to collect more accurate information about the patient. The calculated heart rate is below the normal range which demonstrate that heart is unable to pump enough amount of blood throughout the body (Mandal, Seethalakshmi, and Rajendrababu, 2020).

Question 3: (100 - 200 words)

You will need to do a verbal ISBAR handover for Mr. McFarlane to the Emergency Team when they arrive. Consider what you need to say & write your plan here in ISBAR format.

Response:

I :- I stands for identification. In this case study, Mr. McFarlane ;is a patient, diagnosed with cardiac arrest. I am a nurse called by his wife to improve patient's current medical condition.

S:- S stands for situation. I found patient in lying in a supine position. He was experincling shortness of breathe. I observed pale and clammy skin with slight cyanosis around his lips and peripheral extremities. His eyes were closed and not opening when I called his name. ;

B:- B stands fro background. I called at 13:42 hours by Mr. McFarlane's wife when she found her husband lying on floor and breathless.

A:- A stands for assessment. Patient is diagnosed with lower blood blood pressure, decreased level of SpO2 and decreased respirator rate (Sharma, Nuttall, and Kalyani, 2020). ;

R:- R stands for recommendations.

I performed CPR.

Placed ECG leads.

Inserted IV cannula.

Question 4 (100 - 150 words)

;The Emergency Team have stabilized the condition of Mr McFarlane. However, his condition remains at risk.

Considering your current concerns about Mr. McFarlane, revise his care plan on the template below:

Outline two (2) new nursing diagnoses/problems/ risk factors associated with Mr McFarlane's current health presentations (these nursing diagnoses or risk factors cannot be the same ones used in Assessment 1, Part A)

Identify and explain at least one (1) expected outcome(s) Write ONE nursing intervention with rationale that could be instigated for each diagnosis.

Specify at least one (1) member of the multidisciplinary team that may be able to support your suggested interventions.

Response :

Nursing diagnosis/Client problems

Expected outcome

Nursing intervention

Rationale

Multidisciplinary member to provide support

Patient can not open his eyes when called his name (Hockenberry, and Wilson, 2018).

Due to dizziness, patient is not able to open his eyes (Park, Hanchett, and Ma, 2018). ;

Check eyes for reaction to light. Patient is hospitalised for the further assessment and treatment.

Patient can not be provided appropriate treatment at home.

Nurse collaborated with doctor to provide appropriate treatment to the patient. ;

Congenital heart defects is observed as a risk factor associated with the patient.

It results irregular heart beat;and shortness of breathe.

Myocardial systemic perfusion is improved and fluid volume is reduced.

Myocardial systemic perfusion is required to improved as it helps to avoid overloading.

Doctor along with nurses are required to improve myocardial systemic perfusion (Tosun, and Sinan, 2020).

Question 5: Nursing Documentation (100 - 150 words)

Document this event in Mr McFarlane's case notes in the form of a Progress Note. This is an episodic entry- you can use either the Narrative, SOAPIE or PIE formats

Consider the following:

Vital signs and any clinical observations

Any identified safety concerns

;Nursing Assessments

Nursing interventions

Members of the multidisciplinary team you engaged or referrals you made

Evaluation of care provided

Any other relevant information

Response :

Date & Time

Name, Signature and delegation

Nursing:

Mr. McFarlane is diagnosed with cardiac heart arrest. He is found breathless, in supine position. CPR is performed in order to manage a normal respiration rate. ;Nurse placed ECG leads, inserted IV cannula, checked pulses and applied defibrillation pads to improve patient's heart rate, blood pressure and respiratory rate. The patient was observed with Pale and clammy skin with slight cyanosis around his lips and peripheral extremities. His eyes were not opening when called his name. Need essay help? Talk to our experts now!

Question 6. (Word count 100 - 150 words for each Indicator/ Standard chosen)

The Nursing and Midwifery Board of Australia (NMBA) Enrolled nurse standards for practice;are the core practice standards that provide the framework for assessing EN practice. ;These standards also provide communication to the public about the standards that are expected from EN's. All of the decisions you make as an Enrolled Nurse should align with these standards.

Please utilise the following link to access the Enrolled nurse standards for practice:https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/enrolled-nurse-standards-for-practice.aspx

Please choose ONE indicator per standard from the list below. ;;Review your chosen indicator per standard and reflect in 100 - 150 words per indicator, your understanding of each of your chosen indicator per standard. In your response consider how the indicator relates to care provided to Mr McFarlane.

NMBA “Standards for Practice”: Enrolled Nurses:

Standard 3:

Indicators:

3.1 :- Practice in enrolled nurses related to the reference of legislation, practices and experiences.

3.2:- Describe responsibilities and roles of nursing to prove quality care to patients.

3.3:- It identifies registered nurses as a person reliable to help enrolled nurses for provision and decision making.

3.9:- It promotes safety of nurses as well as patients.

Standard 4:

Indicators:

4.1:- It utilises a set of techniques and skills involving physical examination and measurement, interview and observation.

4.2:- It allows nurses to collect accurate data, utilise, monitor, interpret and transfer the relevant data in order to reach desire health and care reports.

4.3:- Maintain, develop and monitor the patient care plan by collaborating registered nurses and multidisciplinary teams. ;

Standard 5:

Indicators:

5.2:- Multidisciplinary healthcare teams are collaborated

5.3:- it contributes to development and improvement of patient's care plans.

5.4:- It prioritises and manages workload as per the care plan of patients (Young, and et. Al., 2020).

Standard 7:

Indicators:

7.1:- Gather the relevant data and review the health status of the patient.

7.2 :- Reports and interpret health status of people getting registered nurse care.

7.4:- Deliver and prepare health reports in order to handover to multidisciplinary care team.

7.5:- Appropriate and accurate information are provided to make effective decisions.

References required

Response:

maxim maximum um maximum

Question 7. (Word count 50-100 words)

Complete the following table on Emergency codes and corresponding events commonly used in hospital settings.

State the code initiated in Mr. Mc.Farlane's case scenario in Q1.

References required

Response:

Code Name

Event

Red

Hospital caught fire.

Blue

Blue code is used to make the blue team alert ;that a person has a cardiac arrest.

Purple

Purple code is used when a person is caught with threat of violence or threat of weapon.

Yellow

Yellow code indicates a case of emergency.

Black

Black code is used in reference of bomb or threat found at within healthcare centre.

Brown

Brown code is used accidental defecation.

Orange

Orange code is used for spill incident or hazardous material.

Code used in Mr. Mc Farlane's scenario was