Discuss the data/information collected and process that information in terms of relevance to their nursing care using DRABC
Nursing caring and inquiry: foundational
This written assessment asks students to use the clinical reasoning process and refer to evidence based practice to formulate a nursing plan of care for a specific case study selected. After reflecting upon analysing and researching the information provided in the case study students will address each of the following tasks:
1. Critically analyse the patient assessment findings taking into consideration the persons situation and medical diagnosis. Discuss the data/information collected and process that information in terms of relevance to their nursing care using DRABC ( danger response airway breathing circulation) (10 marks)
2. Identify three (3) nursing diagnoses for this person;
One of which must address the clients psycho-social needs.
The nursing diagnoses must be discussed in order of priority (e.g.: what nursing diagnosis should be addressed first and why).
You must also establish one patient centred goal for each nursing diagnosis. (5 marks)
3. For each nursing diagnosis
discuss the specific nursing interventions (what you would do and why) that would be appropriate.
Each intervention must include detailed rationale (why you did what you did) and specific evaluation criteria (how will you know if the intervention was successful).
Your nursing interventions must be person or family centred and must be specific to this client (e.g. tailor the intervention to meet the needs of this specific patient based on evidence and professional recommendations).
All interventions must be referenced from professional literature. (20 marks)
The quality of your academic writing will be assessed throughout each of these three sections and will contribute to your overall mark for that section.
Please see 6h for specific guidelines for formatting an academic paper. Additional marks will be awarded for using correct APA format and referencing throughout your paper (5 marks).
You are a student nurse assigned to a morning shift on a general surgical ward of an acute care facility. You arrive early before the shift starts to review your patients notes in order to better plan your nursing care. Please select one person from the two listed to complete your written case analysis report using the information provided below.
Case Study 1
You are caring for Mr. Harry Flanagan who is Day 4 since his admission to hospital.
Mr. Harry Flanagan is a 24 year old man who was a passenger in a car involved in a head-on
collision with another car. Harrys car was travelling at approximately 60 km/ hour. Harry
arrived at the Emergency Department about 35 minutes after the collision. He was not trapped
in the car although the ambulance were required to extract him because he couldnt move his
left leg because of the pain and because of other potential injuries.
Harry has no significant medical history. He is normally fit and healthy. He has no allergies.
Social History: Harry is employed as a real estate agent; he has just bought an apartment and
has recently become engaged to his partner Janelle. They have an 18 month old daughter
Sophie. Harry moved to Canberra from Alice Springs three years ago to play rugby.
Day 1 3.30 pm: Arrival in ED :
BP: 153/ 74 mm hg
HR: 112 beats/ minute
RR: 22 breaths / minute
Temp: 35.9 OC
SpO2: 96% on room air.
Harry complained of pain in the right side of his chest that was 4 out of 10 in intensity. There
was considerable bruising in this area consistent with the location of Harrys seatbelt. An ECG
was performed which showed normal sinus rhythm.
The paramedics had placed a splint on Harrys left leg. He had complained of pain of 8/ 10
intensity at the site in the left leg prior to the application of the splint. He was administered a
total of 20 mg of Morphine prior to his arrival in ED which reduced his pain to 5/ 10. He was
found to have a large laceration to his left thigh approximately 20 cm long. The paramedics
reported that it had been actively bleeding when they arrived; it is now covered in a pressure
Two large bore cannulas were inserted and blood was taken to test for urea electrolytes full
blood count and his blood group. A normal saline IV infusion was commenced.
Harry had not reported any pain in his neck or back although he was initially immobilised by
the paramedics on a spine board and with spinal precautions until his spine was cleared of
injury- because of the mechanism of injury. X-rays and a CT were performed which showed:
Chest x-ray: No evident rib fractures normal heart size lung fields with good air entry
Acknowledgement: Scully & Wilson (2014) 9049 Assessment 2 Case One Page 2
Pelvic x-ray: Pelvis intact no bone displacement or evident fracture
Limb x-rays: simple closed fracture of left femur with swelling around the left thigh no
other evidence of injuries
Spinal x-ray and CT: no injuries evident.
The blood pathology results were reported as all being within normal range and his blood
group is A+.
Medical assessment determines that although Harrys spinal x-ray and CT were clear spinal
precautions should be taken until the Morphine had worn off because it may have masked pain
on his physical spinal assessment. It was determined that he needed surgery to stabilise his
fracture once the thigh swelling had diminished.
Harrys vital signs were then:
HR: 102 beats/ minute
Resp rate: 20;
Temp: 35.7 OC;
SpO2: 97% with oxygen at 6 l/min via a simple face mask.
Harry is transferred to the ward after a full secondary survey assessment was conducted by
the nurse and a care plan was developed so the nurse could individualise strategies to ensure
the patient had a successful admission. After 24 hours Harrys spine was cleared of requiring
Day 2 following his admission to hospital Harry went to the operating theatre and had an open
reduction and internal fixation (ORIF) of his left femur. He had an uneventful stay in the postanaesthesia
unit where he was cared for for 4 hours before being discharged to the ward with
post op orders for standard post op care including fluids observations analgesia and
enoxaparin. The surgical treating team directed that calf compressors should not be used.
Day 4: Morning Handover:
Harrys progress has been uneventful since then and the night nurse hands over to you. He
specifically mentions that Harry has been having difficulty complying with the
physiotherapists direction to do deep breathing and coughing exercises several times every
hour because of the pain and bruising of his chest. He also reports that Harry hasnt been
complying with the direction to do leg exercises every 2 hours.
You introduce yourself to Harry and take his vital signs that are scheduled 4th hourly:
HR: 92 beats/ minute
Resp rate: 18 breaths/ minute
Temp: 35.6 OC;
SpO2: 97% on room air.
Harry complains to you of pain and swelling in his right calf and you note it is swollen and red.
formulate a plan of care for Harry following the Assessment 2 Guidelines and marking