NRSG378 - Principles of Nursing - Extended Clinical Reasoning Assignment

Assignment Task

Purpose

This assessment enables students to apply knowledge from unit learnings to an issue requiring extended clinical reasoning. The assessment will engage students with the application of theory to practice, and is designed to facilitate an understanding of the impact of illness on the patient. It is also intended to give students the opportunity to demonstrate the ability to use a clinical reasoning framework to plan the care of an acutely unwell patient.

You will be required to respond to the following sections:

1. Patient assessment

• Provide an initial impression of the patient and identify relevant and significant features from the patient presentation. Ensure you identify what the presenting condition/issue/concern is;
• Identify further elements of a comprehensive nursing assessment (this is addition to what has been done already, and can be presented as a list. If you repeat assessments, provide a rationale)

2. Disease pathophysiology and complications 

Discuss in detail, the pathophysiology of the presenting condition/issue/concern and how the patient's presenting signs and symptoms reflect the underlying pathophysiology;

Based on the patient's history and presenting condition, he is at risk for complications. Choose two (2) possible complications from the list below, and explain why he is at risk of developing these. You need to refer back to the patient details to support your answer

• Septic shock
• Fluid overload
• Respiratory failure
• Acute kidney injury

3. Identify nursing issues - Identify and prioritise 3 nursing issues you must address for the patient for their current admission, and justify why they are priorities and support your discussion with evidence and data from the case study. These can be actual or at-risk issues, and need to written using the "issue, cause, evidence" format.

4. Nursing interventions - Identify, rationalise and explain, in order of priority, the nursing care strategies you should use or plan for within the first 24 hours of admission for the patient.

Case study

Shaun Morely is a 35 year-old male who was taken by ambulance to the emergency department (ED) this evening due to worsening cough, shortness of breath, fever, and general weakness, and was accompanied by his husband George. Shaun is only able to speak a few words at a time, before becoming fatigued. George stated that they both tested positive for SARS-CoV-2 virus (tested on PCR) 4 weeks ago, but Shaun has been struggling to recover from his symptoms since then. George noticed that his symptoms were progressively getting worse over the last two (2) days, but they have not been able to make an appointment with their local GP due to a lack of availability.

Shaun states that he has not had an appetite for weeks now, and feels he has lost weight since being unwell (although he hasn’t weighed himself).

A CT scan was ordered which showed bilateral consolidation most likely due to pneumonia, secondary to his initial SARS-CoV-2 infection.

On assessment

• Shaun appears pale, cool and His lips appear dry and his tongue is cracked
• He appears lethargic and George states he “just wants to sleep all the time”
• He is lying in a semi-Fowler’s position but keeps pushing himself upright, while holding his chest
• He has a frequent productive cough, with purulent green phlegm
• Bilateral crackles in the lower and middle lobes are audible on auscultation. Occasional expiratory wheeze noted across all lung fields
• His last urine output was this morning at 9am

Health assessment findings and laboratory results at presentation:

• HR 124 bpm, regular pulse
• BP 95/56 mmHg
• RR 30 bpm, moderate WOB with use of accessory muscles
• Temp 7C
• SpO2 91% on RA
• Alert and orientated to time, place, and person
• CRT 2 seconds
• Weight – 92kg, Height – 65m

Patient history:

Shaun lives with his husband in an outer suburb in Sydney. He is currently studying civil engineering at university full-time, while working at his local café as a barista on the weekends.

Shaun does not smoke and only drinks alcohol on special occasions, but uses a vape daily, although he has stopped since becoming unwell with COVID-19.

Family history:

• Parents live overseas and are both well with no medical concerns

Medical history:

• Asthma, diagnosed as a child although now well controlled

Medications:

• Salbutamol 4-6 puffs via MDI PRN

Management

• Administer IV bolus NaCl 9P0ml over less than 15 minutes
• Commence IV NaCl 9% at 100ml/hr
• Administer IV ceftriaxone 1g BD
• 30/60 vital obs and 1/24 respiratory assessment
• Administer high flow oxygen

You are the registered nurse looking after Shaun, and you are required to plan his care guided by a clinical reasoning framework and the provided case study information.

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