Assignment Task
Neurological
- GCS (hearing and cultural considerations)
- Pupils-PERRLA
- Movement of extremities
- Strength of extremities: equal on both sides
- Does the client follow commands?
- Orientation-person, place and time
- Behaviour
- Stroke scale
- Temperature, Pain
Respiratory
- Characteristics: rate, depth, rhythm, effort
- Lung sounds: crackles/rales, wheeze, rhonchi
- O2 saturation and oxygen equipment
- Cough: productive/nonproductive
- Secretions: colour, consistency
- Swabs, drains and specimens (e.g., COVID, sputum culture)
Cardiovascular
- Apical pulse: count for 60 seconds
- Include: rate, rhythm, S1 &S2 (normal),
- other sounds (S3 or S4?), quality, intensity
- Peripheral pulses: location, strength
- Capillary refill
- Oedema: location, type
- Cyanosis
- ECG changes
Gastrointestinal
- Contour/tenderness/firmness
- Bowel sounds: present x 4 quadrants (normal), hypoactive, hyperactive, absent
- Bowel movement: LBM, characteristics, consistency, consider Bristol stool chart Weight, nutritional status and tolerance for food and fluids, diet modifications BGL
- Tubes, drains and specimens
Gastrourinary
- Urine characteristics: clear, cloudy, haematuria, sediment Intake and output: oliguric, anuric
- Perianal areas: discharge, odour, inflammation
- Catheters: type, 1st void after removal
- Dialysis: AV fistula, days/times, BUN and creatinine
Integumentary
- Colour: conjunctival sac, uniformity.
- Mucous membranes (hydration)
- Temperature, moisture and integrity Location of wounds, dressings and type Turgor
- Pressure Injury risk assessment (e.g., Braden scale or Waterlow)
Pain (last pain med?)
- Location and description:
- P-precipitating factors ( what started the pain? Does anything make it feel better?)
- Q-quality ( what does it feel like?)
- R-region/radiation (where is it and does it go to any other region in body?)
- S-severity (0-10 scale)
- T-time (when did the pain start?)
Vital signs (are they in normal range?)
- Temperature (oral, rectal or tympanic). If hypo or hyperthermic, consider sepsis pathway, blood cultures and antibiotics
- Pulse rate
- Respiratory rate
- Blood pressure
- Pain
Task Instructions
You are a registered nurse caring for a complex patient. You will present the pathophysiology alongside the nursing assessments/investigations and interventions that you would provide, in both poster and verbal formats. The case study will align with a National Health Priority (NHP) area. You must justify your responses and nursing care with the literature and link it to the NSQHS and NMBA Standards and the social determinants of health or health inequity.
The Rationale For Assessment:
The development of comprehensive nursing assessment processes, structured using a systems based approach, allows the registered nurse to effectively plan evidence-based care using relevant and appropriate literature. This is fundamental to nursing – to be able to assess, plan, implement and evaluate care provided to complex patients, giving consideration to social inequities and standards of care (NMBA/NSQHS).
- Consider the pathophysiology of the specific disease process. If a person had this disease, what would be their clinical presentation?
- What additional information do you need? Consider what nursing assessments you would like to do to obtain additional information using the body systems
Goal
The goal of this assignment is to demonstrate your nursing skills in analysing a chosen case study. This analysis will present the pathophysiology of the case study, patient assessment and nursing care with consideration of social justice principles/NSQHS/NMBA standards.