Based on your chosen case scenario and in grammatically correct sentences identify: Three (3) priority nursing assessments you would conduct at the commencement of your shift.

Topic:
Nursing care of a patient with a medical condition
Length: 1600-1700 words.

Preparation

1.5 spaced using Arial or Calibri font in size 11 or 12

In clear, coherent Australian English that demonstrates progression towards the standard for written communication for professional nursing practice in Australia

Using appropriate professional terminology
Contents page, title page, introduction and conclusion are NOT required
Unless otherwise indicated, DO NOT use acronyms, abbreviations and/or nursing jargon.
Unless otherwise indicated, grammatically correct sentences and topic paragraphs are required. Dot points are only accepted in the nursing care plan.
No more than 10% over or under the stated word count. Marking will cease at the 10% over mark.
Note: Headings, any task information copied in and in-text citations are included in the word count. 100 words have been included in the word count to account for the headings within the nursing care plan template.
Use of trade names is not acceptable. Only generic terms or names are to be used when referring to specific medications or other prescribed treatments or resources that may be used in nursing practice
Referencing

Students are reminded of their academic responsibilities and professional nursing practice requirements when using the work of others in assignments.

Reminder marks are allocated for academic integrity. See the marking criteria for full details. Breaches of academic integrity will be lodged on the University system and may have serious consequences for students.
All information is to be interpreted and restated in your own original words demonstrating your ability to interpret, understand and paraphrase material from your sources.

CDU APA 7th referencing style is to be used for both in-text citations and end of assessment reference list.
All resources should be from quality, reliable and reputable journals relevant to nursing practice and the Australian healthcare industry. Please DO NOT use patient information leaflets or websites.
All resources must be dated between 2011 and 2021
There must be at least 15 peer-reviewed journal articles and/or evidence-based practice guidelines cited in your assignment.
Do not use any health facility or local health service policies or procedures.
Only 1 current Australian medication textbook and 1 current Australian medical surgical nursing textbook to be referenced.

complete the assessment task on the next page.

Assessment : Case scenario

Shift handover:

Identify: Miss Grace Orun, HRN: 123567, DOB: 07/05/2005
Situation: Grace is a 16-year-old caucasian female. She has been admitted to the medical ward due to Diabetic Ketoacidosis.
She has a 2/7 history of feeling unwell, fatigue, and a fever. Her Mum was worried as Grace has been complaining of increased thirst and passing large amounts of urine frequently. Her Mum brought her to the emergency department (ED). She was treated for DKA in ED. She has been reviewed by the
Endocrinology team and has been diagnosed with Type 1 Diabetes Mellitus (T1DM) and subsequently developed DKA. She has been transferred to the CDU Medical ward for continuing care.

Background:
Grace lives with her parents and younger brother Tommy. She is independent with her cares and plays Netball at state level 3 times a week after school.
She has never been admitted to hospital before.
Her past medical history:
Previously ankle sprain in 2020 – resolved.
Tonsilitis.
She is allergic to Penicillin.

Assessment:
Airway: Own, patent
Breathing: RR 26, Sats 98% on RA.
Circulation: HR 115 bpm, BP 90/55 mmHg.
Disability: GCS 15/15
Exposure: Temp 37.8 oC
Grace feels tired and anxious.
Grace has 2 x IVC’s inserted to both ACF’s.
She is refusing to eat, feels sad and tells you ‘Leave me alone, my life is ruined, I’ll never play sport again’

Venous Blood Gas attended shows Potassium 3mmol/L
BGL 25mmol/L
Ketones – 1mmol/L

Recommendations/Read back:
Medical orders
Routine ward assessments and observations
Strict fluid monitoring
Administer Intravenous fluids as prescribed
Commence Insulin sliding scale
MSU for MC & S
Diabetic diet and fluids as tolerated
TED stockings and DVT prophylaxis
IV Fluid orders
Intravenous compound sodium lactate (CSL) 500mls over 2 hours followed by:
Intravenous Potassium Chloride 40mmols/1000mls over 8 hours
Medication orders
Actrapid insulin (sliding scale) S/C
Insulin Glargine 10 Units S/C OD
Tazocin 4.5g IV TDS (allergic to Penicillin)

Nursing orders

Devise a plan of care for your patient.

Assessment Tasks:

Using the template provided on the separate document and, based on the handover and information above, other information included below and current reliable evidence for practice, address the following tasks.

Do not make up or assume information in relation to or about your chosen patient. Only use what you know from the information you received today.

Task 1: Assessment

Based on your chosen case scenario and in grammatically correct sentences identify:

Three (3) priority nursing assessments you would conduct at the commencement of your shift.

AND

For each assessment you have identified explain:

Why it is necessary for the patient’s condition and nursing care?
What consequences can occur if this assessment is not completed accurately?
What chart or document could you use to assist with/record your assessments?

(Approximately 400-500 words)

Task 2:

Based solely on the handover you have received and using the template provided on the separate document, complete a nursing care plan for your patient. Your plan must address the physical, functional, and psychosocial aspects of care.

Three (3) nursing problems have been provided for you on the separate document. For each nursing problem on your care plan you need to identify;

What it is related to?
Goal of care
Interventions
Rationales for interventions
Evaluation

Notes for Task 2 only

Dot points may be used in the care plan template.

Appropriate professional language must be used – legally recognised abbreviations may be used in this task (care plan) but a KEY with full terminology must be provided after the assignment references – key will be excluded from word count tally.

Rationales must be appropriately referenced (Only rationales need referencing in the care plan)
(Approximately 400 words)

Task 3: Patient education

Discharge planning

An important aspect of nursing practice is to effectively and succinctly communicate relevant information related to ongoing disease management or prevention of reinfection or deterioration on discharge.

Patient education and discharge planning starts on admission and you need to provide your patient with education during your shift in preparation for discharge home.

Explain two (2) important points/topics you will need to include in your patient’s preparation for discharge to aid healing and prevent further illness. For each education point identified provide:

One (1) strategy to assist your patient to implement the education into their daily routine.

(Approximately 400 words)

Task 4: Medication

Calculate the hourly rate of the compound sodium lactate and the sodium chloride infusions. List the formula that you used.

Choose two (2) medications that your patient has been prescribed (one (1) from their IV fluid order and one (1) from their medication order) and include the following in your discussion:

Describe the pharmacokinetics of the fluid/medication?
Why has your patient been prescribed this fluid/medication?

Discuss any side effects that could affect the patient.

Keep in mind that Grace is Alergic to Penicillin however is prescribed – Tazocin 4.5g IV TDS – discuss the elements of pharmacokinetics but highlight that this is either a drug error or you would not give, and state why.
(Approximately 400 words)

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