NSB010: Clinical Judgement and Decision-making in Nursing - Nursing Assignment Help

Assignment Task:

Assessment Name:

Clinical Judgement and Decision-making in Nursing: A Case Study 

Task Description:

Drawing on the case study below, you will use relevant and current evidence to describe an approach to assessment linked to underlying pathophysiology and develop and report an initial evidence-based plan for care. 

What You Need to Do: CASE STUDY – Frank Vorster 

Suzanne Vorster is a 72-year-old woman who lives at QUT’s Happy Valley Aged Care Facility in Brisbane. You, a QUT graduate nurse, enter Suzanne’s room and find her in her bed as is shown in the picture below. 

She tells you she has difficulties breathing. Suzanne has a medical history of Chronic Obstructive Pulmonary Disease (COPD) caused by a history of long-term smoking. Two years ago, she was diagnosed with Alzheimer’s Disease (AD). For COPD treatment, she uses bronchodilator therapy and corticosteroids via inhalers. She also has continual oxygen therapy running at 2 litres of oxygen per minute. In the last year, she started on a daily Exelon 10 Transdermal patch to reduce the symptoms of AD. Four months ago, she received the annual influenza vaccination and pneumococcal pneumonia. When you cared for her yesterday, she had no problems breathing.

After reading the case study respond to questions 1 and 2. 

Question 1:

A. Describe and justify what two (2) nursing assessments you would perform as a priority.

B. Considering the situation and her medical history (picture and case study), identify two (2) factors that could have contributed to her dyspnoea and explain these factors in relation to underlying pathophysiology. Support your response with relevant and current evidence.

C. Using the SMART Goal framework, identify the priority goal for care.

D. Using current and relevant evidence, identify and justify two (2) nurse-initiated and evidence-based interventions to positively impact on Suzanne’s situation. 

Question 2:

Based on Suzanne’s situation document a written entry into the progress notes. Your report must use the SBAR framework and accurately report the situation (Situation), identified risk factors for her dyspnoea (Background), findings from the initial assessment (here you may make up assessment findings that you would expect when observing Suzanne) and interventions suggested in Q1 (Assessment) and how the interventions should be evaluated (Recommendations).

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