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Assessment Task 3: Case Study 1500 words (+/- 10%).
During clinical placements, students are to select a patient in their care and to undertake a thorough clinical assessment and case study. Students must discuss their choice of patient with their facilitator and should also obtain appropriate consent prior to assessment and use non identifying information in the case study submission.
Patient Information
Name (pseudonym):- _____________________________________ Age:- ___________ Gender:- _________
Admission Diagnosis:- _____________________________________ Past Medical History:- _________________________
_______________________________________________
Past Surgical History:- _____________________________________
_______________________________________________
__________________________________________________________
__________________________________________________________ Current Medications:- __________________________
________________________________________________
Immunisation status:- _____________________________________
________________________________________________
Allergies:- _____________________________________ ________________________________________________
Next of kin:- _____________________________________ General Appearance :- __________________________
Nursing Observations: - ________________________________________________
Temperature: - ______ Pulse: - _______ Respirations: - _______ Brief overview of patient: ____________________________
BP: - _________ Weight: - _________ Height/Length:- _________
Urinalysis: -
Interpretation of nursing observations:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Anatomy, physiology and pathophysiology of admission diagnosis:-
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Diagnostics:-
Pathology:-
Reason(s) for particular tests
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Findings:
___________________________________________________________________________________________________________________
Radiology: -
Reason(s) for particular tests
___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Findings:
___________________________________________________________________________________________________________________
Other: -
Reason(s) for particular tests
__________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Findings: __________________________________________________________________________________________________________________
IDENTIFY 6 FUNCTIONAL HEALTH PATTERNS IN PRIORIY ORDER (with 1 the most important) THAT HAVE BEED AFFECTED BY THE CURRENT (or past) DIAGNOSIS. Include the reason why each functional health pattern has been affected and was given a 1-6 priority order
1.0 ___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
2.0 ___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
3.0 ___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
4.0
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
5.0
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
6.0
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Provision and coordination of care: Nursing Care Plan
Complete the following Nursing Care Plan related to the first 3 functional health patterns that were affected.
Nursing Diagnosis: NANDA Approved
Manifested by (Presenting symptoms) Management strategies and rationales
1.
Related to (Aetiology):
2.
Related to (Aetiology):
3.
Related to (Aetiology):-
Prepare a brief handover report for your patient using ISBAR.
References
Marking criteria:
Adherence to case study criteria : Linked to the provision and co-ordination of care for a patient requiring acute med/surg care.
All areas addressed in-depth
Evidence of consolidation of learning.Analysis, critique and synthesis The case study was articulate, logical, balanced and convincing. A diverse range of perspectives was offered. All important aspects are covered demonstrating comprehensive knowledge of the key areas
Evidence to support the analysis An extensive range of relevant literature utilised with sophisticated interpretation and analysis
Organisation,
Presentation and
ReferencingFlawless presentation.
During clinical placements, students are to select a patient in their care and to undertake a thorough clinical assessment and case study. Students must discuss their choice of patient with their facilitator and should also obtain appropriate consent prior to assessment and use non identifying information in the case study submission.
Patient Information
Name (pseudonym):- _____________________________________ Age:- ___________ Gender:- _________
Admission Diagnosis:- _____________________________________ Past Medical History:- _________________________
_______________________________________________
Past Surgical History:- _____________________________________
_______________________________________________
__________________________________________________________
__________________________________________________________ Current Medications:- __________________________
________________________________________________
Immunisation status:- _____________________________________
________________________________________________
Allergies:- _____________________________________ ________________________________________________
Next of kin:- _____________________________________ General Appearance :- __________________________
Nursing Observations: - ________________________________________________
Temperature: - ______ Pulse: - _______ Respirations: - _______ Brief overview of patient: ____________________________
BP: - _________ Weight: - _________ Height/Length:- _________
Urinalysis: -
Interpretation of nursing observations:
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Anatomy, physiology and pathophysiology of admission diagnosis:-
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Diagnostics:-
Pathology:-
Reason(s) for particular tests
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Findings:
___________________________________________________________________________________________________________________
Radiology: -
Reason(s) for particular tests
___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Findings:
___________________________________________________________________________________________________________________
Other: -
Reason(s) for particular tests
__________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Findings: __________________________________________________________________________________________________________________
IDENTIFY 6 FUNCTIONAL HEALTH PATTERNS IN PRIORIY ORDER (with 1 the most important) THAT HAVE BEED AFFECTED BY THE CURRENT (or past) DIAGNOSIS. Include the reason why each functional health pattern has been affected and was given a 1-6 priority order
1.0 ___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
2.0 ___________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
3.0 ___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
4.0
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
5.0
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
6.0
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Provision and coordination of care: Nursing Care Plan
Complete the following Nursing Care Plan related to the first 3 functional health patterns that were affected.
Nursing Diagnosis: NANDA Approved
Manifested by (Presenting symptoms) Management strategies and rationales
1.
Related to (Aetiology):
2.
Related to (Aetiology):
3.
Related to (Aetiology):-
Prepare a brief handover report for your patient using ISBAR.
References
Marking criteria:
Adherence to case study criteria : Linked to the provision and co-ordination of care for a patient requiring acute med/surg care.
All areas addressed in-depth
Evidence of consolidation of learning.Analysis, critique and synthesis The case study was articulate, logical, balanced and convincing. A diverse range of perspectives was offered. All important aspects are covered demonstrating comprehensive knowledge of the key areas
Evidence to support the analysis An extensive range of relevant literature utilised with sophisticated interpretation and analysis
Organisation,
Presentation and
ReferencingFlawless presentation.
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