Highlights
Darren is a 51-year-old male who lives in Cairns where he is the owner/operator of a diving boat tour company. He has moved to a more sedentary role over the last few years and misses getting out and working with the tourists. Darren has one son, Jake, 15 who lives in Wallan, Victoria with his mum Lisa, stepdad Kevin and his 5-year-old stepsister Ruby. Jake and Darren have a good relationship, Jake fly’s to Cairns twice a year during school holidays to stay with his Dad.
Darren’s History
DOB: 23/11/1968
Address: 25 Happy Street Cairns
Smoker: 30 per day for last 20 years
Social Drinker 2 heavy beers a day after work and up to 10 a day on the weekends - Darren’s favourite saying -It’s 5 o’clock somewhere’
^BMI -33 H: 1.8m W: 110Kg Waist: 115cm
Darren has a past medical history including, hypertension, hyperlipidaemia, mild depression and GORD. He currently takes medication for these conditions.
He has experienced two episodes of upper abdominal pain during the night with associated nausea and vomiting within the last month.
Darren does not attend regular check-ups with his GP. He last had his medications reviewed when he presented to the GP around 12 months ago with his first presentation of upper abdominal pain, nausea and vomiting. He was commenced on Ranitidine at thiis time.In the last month, Darren has had two more severe episodes of upper abdominal pain with nausea & vomiting. He ignored the first episode and it settled after 24 hours. However, Darren has presented to the Emergency Department in Cairns 1/7 ago with similar symptoms but more severe.Darren’s diagnosis is mild- severe Cholecystitis. Darren has been transferred to the surgical ward where he is awaiting an elective Laparoscopic +/- Open Cholecystectomy. Darren has had pre- operative blood pathology collected including his Cholesterol, which is reading high. This is part of Darren’s pre-operative work up. When possible removal of the Gallbladder is done Laparoscopically, which is also known in lay mans terms as 'key hole' surgery. Laparoscopic Cholecystecomy is a minimally invasive, low risk procedure that is often done in Day Procedure or requires only an overnight stay in hospital.
Clinical Case Study
Relevant SILOs:
1. Apply the Australian Nursing and Midwifery Board [ANMB] Standards of Practice for a Registered Nurse when caring for individuals and their families, with Cardiovascular, Respiratory and Endocrine disorders.
2. Describe the impact of hospitalisation on individuals and their families.
3. Provide person-centred care, using the Clinical Reasoning Cycle to individuals experiencing Cardiovascular, Respiratory and Endocrine disorders.
Rationale: The purpose of this assessment task is to assess the student nurse’s ability to think critically and apply the clinical reasoning cycle to plan patient care.
As a Registered Nurse, you will be required to make judgments and prioritise your patients care multiple times per shift. This assessment task is designed to develop the sophisticated thinking abilities that are essential to prioritising, planning and providing safe and effective patient-centred, nursing care.
Task: Nursing Problem Statements [ensure that you are aware of the correct problem statement for your cohort -see the table in Assessment block on LMS].
In this Clinical Case Study, you have been allocated, depending on your cohort, one (1) of the nursing problems provided below. You are to discuss its relevance, then plan and evaluate patient-centered, nursing care. The nursing problems all relate to Darren Roberts’ care in the first 4 hours following his discharge from PARU and return to the ward following his surgery.
Required Sections:
• Discuss the importance of the Nursing Problem you have chosen and why it is a particular risk for Darren in the first 4 hours of his return to the surgical ward.
• Use Darren’s data and documentation from the Enquiry to inform this discussion; this does not require APA6 referencing.
• Use evidenced-based nursing literature to support your discussion; this does require APA6 referencing. Approximately 500 words
• Write one Patient-Centred SMART Goal for Darren’s Nursing Problem that you have selected. Approximately 1 to 2 sentences
• Provide three (3) relevant Nursing Interventions designed to achieve the selected SMART Goal. Discuss each intervention separately and include evidenced-based rationales for the intervention; this does require APA6 referencing. Approximately 600 words (200 for each intervention)
• Discuss the evidenced-based assessments you would use to evaluate the effectiveness of implemented nursing interventions; this does require APA6 referencing. Approximately 400 words
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