NRSG370 - Clinical Integration - Peter Ling Case Study - Speciality Practice - North Sydney - Nursing Assessment Answer

NRSG370 - Clinical Integration - Peter Ling Case Study - Speciality Practice - North Sydney - Nursing Assessment Answer

Assessment Task:

Case Study

Mr Peter Ling: Post-operative inguinal hernia repair 

Mr Peter Ling a 67-year-old man who is admitted to the Surgical ward, following an open mesh inguinal hernia repair. He had presented to ED with a 6-hour history of a Rnon-reducible tender, inguinal mass, post commencing a new gym/weight lifting regime. 
Past Medical History:Mr Ling is retired, lives with his wife, ex-smoker and is obese, with a body mass index (BMI) of 30. Incidentally,he is an ex weight lifter. He is on medication for hypertension and hyperlipidaemia, which are both well controlled, and he also has mild congestive heart failure (CHF). 
Mr. Ling was recovering well, but on Day 2 post op, he hasbecomea little agitated and confused, complaining of significant left calf pain.

On your assessment:
•    Vital signs:Temp: 39.3oC, RR: 25, HR:100 regular, SpO2 95% on room air (R/A), BP: 170/90, Pain score 7/10 (wound site and left calf), GCS 14/15
•    Physical assessment: Mr. Ling is restless and confused to time and place. His chest is clear, skin is dry, post-op surgical wound dressing is oozing green purulentdischarge and tender to touch. His leftcalf appears larger than the right and it is red, and warm to touch. 

Investigations:
•    Haemoglobin 16.5 gm/dl,
•    WCC, neutrophils and CRP – all elevated

Nursing notes:
•    Mr. Ling has an 18g Cannula in his Right arm
•    He has tolerated diet and is voiding well
•    Bowels opened yesterday
•    Agitated and confused to time and place on assessment this am.

You are the registered nurse looking after Mr. Ling. 

NRSG370 - Clinical Integration - Speciality Practice Assessment: Case Study Outline- Information for Students Assessment 3: Case Study - North Sydney The Clinical Reasoning Cycle 

Student are expected to use the Clinical Reasoning Cycle (Levett-Jones, 2018) as a framework to plan and evaluate person-centred care. You are being asked to think through the case scenario and then discuss how data was collected and the type of data collected, identify problems and nursing issues, identify and state the objectives and discuss how care was provided in order to address the issues and evaluate the interventions carried out: (analyse and identify a nursing issues/problems/needs, set objectives, discuss the nursing interventions and evaluate the interventions of care carried out). As per lecture notes, students are expected to apply the clinical reasoning cycle to address the case scenario: 
•    Consider the person’s situation 
•    Collect, the information
•    Processing gathered information
•    Identify and prioritise at least three (3) nursing problems/issues based on the health assessment data that you have identified for the person at the centre of care. 
•    Establish goals for priority of nursing care related to the nursing problem/issues identified 
•    Discuss the nursing care of the person; link it to assessment data and history. 
•    Evaluate your nursing care strategies to justify the nursing care provided 
•    Reflect on the outcomes

a)  Consideration of facts from the patient or situation 
Consider the case scenario of your choosing based on your clinical elective as per assessment “Choose the one that best reflects your specialty placement” this is where you determine what information should be collected and how information is going to be collected. 

b)  Collection of information 
You need to discuss the type of information collected and why this information was collected based on the scenario for the clinical elective. For instance, the type of information collected should consider and include the history, current presenting issues and treatment plan, observations, results of investigations done medical records etc. 

c)  Processing gathered information (analysing and interpreting) 
The most important thing is to analyse the information that you have collected and identify areas of nursing care needs and problems. In this section, your discussion should reflect analysis and interpretation of the patient’s current health status using your established knowledge of physiology, pharmacology, pathology, culture, and ethics to establish needs and issues drawn from the information. This stage allows you to demonstrate synthesis of theory and experience acquired in previous and concurrent nursing units. ( In this part, you should focus on why Mr peter temp is high, why his BP is high, why his haemoglobin is low, what could be the reason his wound is infected??)

d) Identify theproblem 
Identification of nursing problems based on the clinical scenario and the condition. Identify three nursing problems (You need to support and give rationale to support the identification of the problems. Identify and discuss one problem at a time). This stage requires of you to read and look for literature to support what you are talking about. Do not concentrate on the pathophysiology but you need to give rationale based on the understanding of what causes the problem;  
Example;  state the problem and the likely cause of the problem as per condition and why the problem has occurred or is likely to occur 
1.    Potential to develop dehydration supported by patient vomiting and loose bowel motion three times  (explain and given rationale relate to scenario) 
2.    Pain due to post -operative procedure – laparotomy 
3.     -------------------
o    Do not just identify the problem give a short explanation 

e) Establish goals 
• Here, you determine the nursing goals for the patient’s situation. Identify and prioritise at least three (3) nursing problems/issues based on your assessment and collected data. 

f) Take action
A significant amount of discussion should be attached to this section to reflect how you would address the three areas identified issues 
• Here you discuss the nursing interventions or measures you will undertake in order to address the three nursing issues or problems. These measures should take in consideration the ethical, legal, evidence based, holistic -person-centred approach. discuss the nursing interventions that you would carry out to manage this condition or issue; give rationale to substantiate what you are doing and why you are managing the condition  the way you are based on the clinical/client condition supported with literature  

g) Evaluation and Reflection 
• Evaluate the effectiveness of the nursing interventions you have discussed (presumably which could have been carried out or actually carried out) and reflect on how the interventions could have been improved or done better- State the potential measures that could have been considered or could have been carried out to address the problem. This phase allows you to critically analyse what has been done and how best the care was carried out or could have been improved. 

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