Assessment 2 Case Study NURS2004 2023 Paul Rook is a 52-year-old Indigenous Australian who lives in a large rural city in New South Wales. He lives with his wife, Sally, and 16-year-old daughter, Georgia. He completed his school certificate (year 10)
NURS2004: Assessment 2 Template
Instructions
This template has been developed for you to use to complete Assessment Task 2: Case Study. It includes the information for the relevant sections of the marking rubric and space for you to complete each part of the assessment task. The portions of the template that you must enter your identifying details (name and student number) are highlighted in yellow. Please refer to the Canvas for details on the assessment, the case study, marking criteria, as well as standards, presentation, and referencing requirements. Make sure that you add a reference list to the end of this document and include in-text referencing to acknowledge your sources throughout the document in accordance with the referencing requirements in the Course Outline.
Assessment Task 2: Case Study (2000 words)
Consider the patient situation
Provide an overview of the scenario.
(Identify and describe the person, context, and situation).
(Approx. 150 words) Overview of Scenario
Collect cues/information
Identify relevant cues related to current information.
(Approx. 200 words)
Cues
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
Process Information
Identify five (5) priority cues and explain why the cues are a priority for the medical patient. Reference/s needed.
(200 words)
5 Priority Cues Explanation
1. 2. 3. 4. 5.
Identify the problems
Identify one (1) nursing diagnosis for the medical patient based on the prioritised cues. Present the diagnosis using related to and evidenced by statements.
(100 words)
Diagnosis
Establish (SMART) Goals
Identify two (2) person-centred goals for the medical patient that are linked to the nursing diagnoses. Present the goals using SMART criteria.
(100 words) SMART Goal 1
SMART Goal 2
Select a course of action
Outline three (3) nursing interventions for each identified goal that will assist the medical patient to meet the desired outcomes. Provide brief evidence-based rationales for each intervention.
(800 words total)
Intervention 1 for SMART Goal 1 Rationale
Intervention 2 for SMART Goal 1
Rationale
Intervention 3 for SMART Goal 1 Rationale
Intervention 1 for SMART Goal 2 Rationale
Intervention 2 for SMART Goal 2 Rationale
Intervention 3 for SMART Goal 2 Rationale
Evaluate
Explain the process for evaluating the desired outcomes in the scenario.
(200 words)
Outcome
Reflection
Use the SPROUT model of reflection to consider what you have learned from completing this task and how it will contribute to your future practice.
References needed.
(250 words) Reflection
References
Assessment 2 Case Study NURS2004 2023
Paul Rook is a 52-year-old Indigenous Australian who lives in a large rural city in New South Wales. He lives with his wife, Sally, and 16-year-old daughter, Georgia. He completed his school certificate (year 10) and left school to begin working as a concreter. He manages his own family run concreting business. Paul is actively involved in his local Aboriginal land council and volunteers as a mentor for indigenous youth. Paul has been an active smoker of tobacco (cigarettes) since he was 16 years old. He was a pack-a-day smoker for 30 years but has reduced his consumption to 5 cigarettes per day in the last two (2) years. Paul has a medical history of hypertension, chronic obstructive pulmonary disease (COPD), obesity (BMI 36.8, Weight 110kg), and depression. He has a family history of bowel cancer, Type 2 Diabetes Mellitus, and heart failure. He is prescribed the following medications:
Perindopril 4 mg orally daily
Escitalopram 10 mg orally nocte
Salbutamol 100 micrograms 2 puffs inhaled PRNTiotropium 18 micrograms inhaled BDAtorvastatin 20 mg orally nocte
Paul presents to the emergency department (ED) of his local hospital experiencing shortness of breath. The triage team provide the following handover:
Paul is a 52-year-old male who presents with shortness of breath. He describes fevers and chills for the past few days and a productive cough with yellow-green sputum. He appears alert and orientated, has an audible wheeze, and is speaking in short sentences. Paul states that he has been using his salbutamol inhaler every two (2) hours. He last used it an hour ago. The following vital signs are recorded at triage:
Consciousness:AlertRespiratory Rate: 28 breaths per minuteSpO2: 91% room airHeart Rate: 100 beats per minute (bpm) and regularBlood Pressure: 165/90 mmHgTemperature: 38.0oCBlood Glucose Level: 6 mmol/LPain: 4/10 whole body ache and chest is sore to touchSkin: Warm and flushed
You are the registered nurse caring for Paul as he is transferred into an acute bed of the emergency department. Paul becomes very short of breath as he transfers onto the bed. He has a loud and productive cough that leaves him gasping for air. He expectorates thick green phlegm and he is visibly distressed. He tells you I cant breathe I. need help. Paul is guarding his ribs and describes a severe and sharp discomfort in his chest. You attend the following vital signs:
Consciousness:AlertRespiratory Rate: 36 breaths per minutewith subcostal recessionSpO2: 87% room airHeart Rate: 115 beats per minute (bpm) and regularBlood Pressure: 170/100 mmHgTemperature: 38.1oCBlood Glucose Level: 6 mmol/LPain: 6/10 sharp chest pain on top of general body ache
Skin: Warm and flushed skin with blue colouration to his fingertips
Identify what actions you would take and develop a plan of care for Paul using the template provided