HNB2008: Evidence Based Case Study Assessment 2

Assessment 2

Case Study

James Peter is a 54 year old male who has previously been diagnosed with anxiety and substance misuse of heroin intravenously. He had a recent episode of pneumonia and was treated with amoxicillin. James is a smoker (tobacco), and regularly drinks excessive amounts of alcohol. James has had issues with housing and is currently homeless. James has no close relationships with family except with his sister Sandra. He is divorced with two children who live interstate with their mother and stepfather. James is a former carpenter who saw a close friend and colleague die after suffering a workplace injury. James was also injured in the workplace incident and required surgery (open reduction, external fixation of left radius). Since then James has developed anxiety and began to regularly use cannabis and is now using heroin. James was dismissed from his job and then his marriage also broke down leading to a divorce. After the divorce James ended up homeless, staying with his sister or in the local men’s shelter He spends time with his sister who also engages in heavy drinking and cannabis use.

James initially presented to the GP with the infected right leg ulcer and was prescribed clarithromycin 500mg BD PO for seven days but was non-cooperative with this treatment. James has now presented to the Emergency Department (ED), with worsening infection in the leg ulcer, cellulitis, and increased pain. James went to theatre and had the ulcer debrided and has come into the vascular ward post-operatively.

James describes his mood as low and reports often feeling stressed and angry. He has previously been prescribed an antidepressant mirtazapine, although has stopped taking this medication, stating it doesn’t work. He also takes oxazepam when able to get a script. He has inconsistently been on a suboxone program, but this has not been charted on this admission yet. When James arrives on the ward he is initially stable with his vital signs and comfortable.

As the shift progresses he reports increased pain as the local anaesthesia given in theatre is starting to wear off. James is becoming agitated and demanding pain relief and beer. He is prescribed 1g paracetamol, 5mg oxycodone 6hrly PRN. James’ sister is visiting and when you are assessing James you notice that his breath smells of alcohol. You speak with Nurse in Charge (NIC), about this and are told that James is an attention seeker, and that he can’t be in that much pain as he had morphine in theatre. In the meantime James is becoming increasingly verbally aggressive and his sister is increasingly belligerent towards you. James is now attempting to pull off the wound dressing and yelling out that he is in pain.

Case Study Question

How would you as a registered nurse (RN) prioritise and manage this situation? To address this question, you are required to identify, rationalise, and explain, in order of priority, a minimum of three priorities of care in the first 24 hours of presentation. Priorities must be supported with evidence.

In your answer you are required to consider the Registered nurse standards for practice, (Nursing and Midwifery Board of Australia [NMBA], 2016), clinical practice guidelines and relevant legislation.

1. Pain management
2. Infection
3. Alcohol and Substacne Use ultilise AWS, refer to AOD services as an intervention
4. (potential) planned code grey due to aggression

Brief summary of assessment requirements (key pointers to cover)

Task: As a Registered Nurse (RN), prioritise and manage the presented case (James Peter) in the first 24 hours. Identify, rationalise and explain in order of priority a minimum of three priorities of care, and support each priority with evidence. Consider the Registered Nurse Standards for Practice (NMBA, 2016), relevant clinical practice guidelines and applicable legislation.

Key pointers you must cover:

• Clear statement of the top priorities of care (minimum three) in the first 24 hours, presented in order of priority.
• A rationale for each priority that links clinical actions to patient safety, physiology, and evidence (clinical guidelines, NMBA standards, hospital policy).
• Specific nursing interventions for each priority (what the RN does, monitoring, escalation).
• Consideration of pain management, infection control/wound care, alcohol & substance use (including AWS risk and AOD referral), and potential aggression / security (planned code grey).
• Integration of legal/ethical considerations (capacity, consent, duty of care, documentation) and team collaboration (MDs, pain team, AOD services, social work).
• Use of standards and guidelines (NMBA Registered Nurse Standards for Practice 2016; local clinical guidelines for analgesia, wound infection and AOD management) to justify practice decisions.
• Clear, concise plan for reassessment and evaluation within 24 hours (what you will check, when, and expected outcomes).

How the Academic Mentor guided the student step-by-step process (each section explained briefly)

The mentor’s approach is practical, evidence-driven and student-centred: break the task into discrete, assessable steps, model clinical reasoning, and require explicit links between standards/guidelines and chosen actions.

Step 1 Clarify the assessment brief and learning goals

• What the mentor did: Read the case with the student; restated the assessment question; pointed out the requirement to provide priorities in order and to reference NMBA standards and guidelines.
• Why: Ensures the student addresses marking criteria and frames the response academically.

Step 2 Conduct a rapid clinical analysis of the case

• What the mentor did: Guided the student to extract immediate red flags (worsening leg infection post-op, increasing pain, alcohol on breath, agitation, heroin history, non-compliance with oral antibiotics, homelessness, inconsistent Suboxone).
• Why: Prioritisation depends on recognising immediate risks (infection/sepsis, uncontrolled pain, intoxication/withdrawal, aggression).

Step 3 Select and order the priorities of care

• What the mentor did: Helped the student decide on an evidence-based order (example below) and required justification for each priority tied to physiology, safety and standards.
• Example order taught:
  1. Ensure safety & prevent harm (patient, staff, wound integrity) includes de-escalation and security planning.
  2. Effective pain management assess and treat promptly to reduce distress and prevent further agitation.
  3. Infection control and wound management ensure antibiotics, wound care, monitor for sepsis.
  4. Manage alcohol & substance use risks screen for intoxication/withdrawal risk (AWS), document, refer to AOD, coordinate opioid substitution therapy.
  5. Psychosocial needs and discharge planning involve social work, housing and follow up, family liaison.
• Why: This order balances immediate safety with urgent clinical needs and medium-term psychosocial interventions.

Step 4 Map each priority to specific nursing actions and evidence

• What the mentor did: For each priority the mentor had the student list: assessment tools, immediate interventions, escalation triggers, monitoring plan, and evidence/standards (e.g., NMBA standards for assessment, documentation and escalation; local sepsis and analgesia guidelines).
• Why: Demonstrates clinical reasoning and links actions to evidence and professional standards.

Step 5 Address legal, ethical and documentation considerations

• What the mentor did: Taught the student to include capacity assessment (if required), informed consent, duty of care when intoxicated or agitated, mandatory incident reporting for aggressive events, and precise contemporaneous documentation.
• Why: Ensures safe, defensible nursing practice and meets assessment criteria requiring consideration of legislation and standards.

Step 6 Plan evaluation, follow-up and referrals

• What the mentor did: Co-developed a 24-hour evaluation schedule (vitals, pain reassessment, wound checks, AWS observations), and a referral checklist (pain service, AOD services, social work, psychiatry if needed).
• Why: Shows the student can measure outcome and coordinate multidisciplinary care.

Step 7 Drafting and referencing

• What the mentor did: Reviewed the student’s written answer for clarity, logical flow, correct use of present/past tense, and evidence-based references (NMBA standards, hospital guidelines, relevant literature). Gave feedback to tighten wording and ensure every claim had a supporting rationale.
• Why: Improves academic quality and ensures the assessment is properly evidenced.

How the Outcome was Achieved 

Process: By following the mentor’s structured approach case analysis, prioritisation training, evidence-linking, drafting, and iterative feedback the student created a clinically sound, well-referenced answer that:

• Presented priorities in clear order,
• Included specific nursing actions and escalation triggers,
• Cited the NMBA Registered Nurse Standards for Practice (2016) and relevant clinical policies, and
• Addressed legal/ethical and documentation requirements.

Result: The student submitted an assessment that met the marking rubric: priorities were justified with clinical rationale and evidence, interventions were realistic and ward-appropriate, and multidisciplinary referrals and evaluation plans were included. The answer demonstrated safe clinical judgement, professional accountability and an understanding of contextual psychosocial factors.

Learning Objectives Covered

By completing this assessment under mentor guidance, the student achieved the following learning outcomes:

1. Clinical prioritisation: Demonstrated skill in identifying and ordering immediate nursing priorities in a complex, multifactorial case.
2. Evidence-based practice: Linked clinical actions to standards (NMBA 2016), clinical guidelines and hospital policy.
3. Safe medication management: Applied principles of analgesia and interaction risk assessment in patients with substance use.
4. Risk assessment and de-escalation: Applied aggression management strategies and safety planning to avoid or manage a code grey.
5. Assessment for withdrawal and AOD referral: Recognised alcohol/substance use risks and initiated appropriate monitoring and referral.
6. Communication and documentation: Demonstrated accurate, timely documentation and effective communication with the multidisciplinary team.
7. Holistic care planning: Incorporated psychosocial determinants (homelessness, family relationships) into discharge planning and referrals.
8. Professional and legal accountability: Showed awareness of consent, capacity, duty of care and mandatory reporting as they apply to acute nursing practice.

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