Assessment One-Case Study

This assessment will consist of a clinical case report. The completed case report will need to be submitted via the Health of Older Adults (NURS 2024) course site Assessment 1: case report link by the assessment due date.

Relevance:

In order to plan and provide optimal person-centred nursing care, Registered nurses need to be able to interpret clinical information and draw upon their knowledge of pathophysiology and evidence-based clinical practice. Therefore, the purpose of this assessment is to support the development of the skills needed to evaluate evidence and to develop reflection and clinical reasoning skills.

What you need to do:

Based upon the clinical scenario provided below, construct a case report which is a detailed report of the client’s clinical presentation, nursing diagnosis and inter-professional plan of care. The case report will draw upon your knowledge of pathophysiology, pharmacology and relevant academic literature to support an evidence-based nursing plan of care.

The case report must be presented using the headings provided below. A description of the content for each section of the report has been provided. It is important that all sections of the report are conceptually connected. For example, your knowledge of pathophysiology and pharmacology, and your understanding of this particular client, should underpin the nursing problems that you identify which should, in turn, drive the inter-professional plan of care that is relevant for this clinical scenario.

Case Report:

The case report must include the following:

Introduction (2.5 marks) – 200 words

Using the ISBAR clinical handover framework, introduce the client and provide a brief overview of their case. Provide an outline of the purpose and structure of the report.

Primary medical diagnosis (3.75 marks) – 300 words

Focus on the most recent primary medical diagnoses for the client (i.e. Cataract) Provide a brief description of the pathophysiology of this recent diagnosis, with clear links to the case scenario. Support this discussion using current evidence-based literature (published within the last 10 years).

Medication management (3.75 marks) – 300 words

Identify and provide a brief description of the current medications (i.e. route, mechanism of action, indication, side-effects and precautions). Support this discussion using current evidence-based literature (published within the last 10 years).

Nursing diagnoses (3.75 marks) – 300 words

Support this discussion using current evidence based literature (published within the last 10 years).

(a) Nursing problem related to medical diagnoses:

Using your knowledge of pathophysiology, document one (1) nursing problem that may arise as a result of the client’s most recent primary medical diagnosis (Cataract). This problem may be an actual or potential nursing problem. Provide a brief description for why this problem may arise for this client.

(b) Nursing problem related medication management:

Using your knowledge of pharmacology, document one (1) nursing problem that may arise as a result of the client’s current medications in relation to the recent primary medical diagnosis. This problem may be an actual or potential nursing problem. Provide a brief description for why this problem may arise for this client.

Nursing Role and Inter-professional Plan of Care (6.25 marks) – 700 words

As the community nurse working as part of the aged care assessment team (ACAT) , discuss how a registered nurse will facilitate an inter-professional plan of care for this client, with consideration to the two identified nursing diagnoses.

Discuss the aim for and importance of using an inter-professional approach. Discuss the role of the Registered nurse to facilitate the interdisciplinary plan of care for this client. Identify specific to the two identified nursing diagnoses the key members of the inter-professional health care team, and their roles. Support this discussion using current evidence based literature (published within the last 10 years).

Summary (2.5 marks) – 200 words

Summarise the major findings of this case report.

Referencing (1.25 marks)

The content of the case report must be supported through referencing of current evidence-based literature and must include a reference list and intext citations. Students will be assessed on referencing, please ensure to follow the UniSA-Harvard referencing style closely to avoid losing marks. Please refer to referencing in Harvard UniSA style https://lo.unisa.edu.au/course/view.php?id=3839

Overall writing and presentation (1.25 marks)

This assignment must be saved and submitted as a word document. This case report must be structured using the headings provided and presented using academic writing. The use of dot-points will result in a reduction of marks. You will be assessed on the overall writing and presentation, so make sure that you follow the academic writing guidelines closely to avoid losing marks.

Clinical Scenario:

As the community nurse for the Aged Care Assessment Team, you are conducting a home visit to assess Mrs Nancy Winter. She has requested approval to receive aged care services and would like to know what her options are.   Mrs Nancy Winter is a 68-year-old retired office worker, who has recently been diagnosed with a cataract in her left eye. Mrs Winters’ previous medical history includes hypertension (diagnosed seven years ago) and severe hearing loss due to Otosclerosis. She has type 2 diabetes mellitus (diagnosed fifteen years ago). Mrs Winters’ General Practitioner (GP) has prescribed her to take Metformin 500mg twice daily and Metoprolol 25mg twice daily.   The referral from the GP indicates Mrs Winter has suboptimal blood pressure and poor diabetes control. The latest blood pressure recorded was 159/96mmHg, heart rate 93 (regular) and her glycated haemoglobin (HbA1C) has never been less than 8%. She also requires a hearing test.   Mrs Winter is a self-described single woman, she has a daughter who lives interstate, and a son who lives locally. She does not drive and relies on public transport to get around town.   Mrs Winter lives alone with her little fluffy dog ‘Moonstar’, in a rented three-bedroom two-story terrace house. Her bedroom is upstairs, while downstairs there is the kitchen and a step leading down into a sunken living room. There is an outdoor veranda with a patio courtyard. The patio paving is in poor repair, and the vegetable patch is overgrown with weeds and the garden could do with some maintenance. Similarly, both bathrooms look like they need a good clean and the laundry has several loads of washing that need doing. The rooms in the house appear cluttered, with ‘keepsakes’ from overseas travels, and old magazines/papers stacked in piles around the home and on the stairwell.   On general appearance, Mrs Winter appears moderately overweight with a flushed facial appearance. She wears glasses for reading. She has a love of reading and doing jig-saw puzzles but has been having trouble recently and described her vision as ‘patchy and blurred’. On questioning, she does admit to feeling ‘dizzy or fuzzy in the head’, and this happens mainly when she forgets to take her tablets with a coffee for morning tea, and so, when this happens she takes them all together later on with her afternoon glass of wine, (or she does not take them at all), but otherwise, she feels in good health. She comments the reason for retirement was because working on the computer had become a bit difficult and it was tiring looking at a screen all day, mainly due to her impaired vision.   Mrs Winter does not test her blood glucose levels at home, she has expressed doubt on why she needed to do it and that it ‘costs too much money’. Mrs Winter has been trying to lose weight for the past 6 months without success. However, she feels now that she is retired, she has more time for exercise, and is not stuck behind a desk all day. For instance, she plans to take Moonstar (the dog) for more walks, do some volunteer work, fix up the vegetable garden and wants to take up social tennis again.   Mrs Winter intends to remain at her rental home and takes pride in her cooking, entertaining friends, and making her own home brewed wine.   On completion of the ACAT assessment a recommendation is made for Mrs Winter to receive an inter-professional community plan of care.

 How will I get assistance to complete this assessment?

Each of the topics delivered in this course will provide content that will give you the knowledge that you will need to successfully complete this assessment.

For example, the weekly learning activities to develop the ISBAR plan of care will prepare you to complete the case report. You should make sure that you read and cite all information provided, use opportunities to discuss this assessment in the weekly tutorials or virtual classrooms.

Students are also encouraged to explore the getting started section for resources for writing a case study.

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