Clients with Complex Health States

 

 

 

 

Professional Experience Analysis Essay :

The University of Melbourne, NURS90053: Clients with Complex Health States

Subject Coordinator: Prue Cambridge

Due Date: Place your own personal due date here

Word Limit: 2,000 (INCLUDES IN TEXT CITATIONS)

Word Count: This is your overall word count

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assignment title repeated here

In this section you need to introduce your essay. You might like to introduce the nursing process here and provide the reader with an understanding of what you plan to discuss in your essay.

 

Introduction to the Patient

This is where you introduce your patient: this includes who they are, what brought them into hospital, their clinical course while in hospital as well as their past history and social history. Make sure to include information regarding support services they may have in place. You should also address any Advanced Care Directives as well as their resuscitation status here. If your patient has a very long list of medications, you can present the complete list as an appendix, but please refer to any specific medications linked to the patient and their presentation in this section

 

Head-to-toe Assessment of Patient

You need to discuss the process you undertook to gather your data (both subjective and objective). Consider the concepts that we discussed in each lecture regarding consent and what did you do to prepare the patient for the assessment. Make sure that you don’t simply omit something because it was within the normal range, and don’t simply state that it is within the normal range. You need to provide detail of the data. Students are also asked to include all data, even if on your ward they don’t routinely undertake a specific test/assessment, you are asked to still undertake the assessment and report on it.

General Assessment

This is where you can provide general patient information and well as your overall impression of the patient including their general appearance

 

 

 

Central Nervous System (CNS)

Here you provide the subjective and objective data that you have accumulated from your patient in regard to this particular body system.  Think here about what we learnt in lectures and labs about how we assess neurological function and report on it.

Cardiovascular System (CVS)

Here you provide the subjective and objective data that you have accumulated from your patient in regard to this particular body system.  Think here about what we learnt in lectures and labs about how you assess cardiovascular function and report on it. Remember to consider all aspects of CVS assessment.

Respiratory System

Again, provide the subjective and objective data that you have accumulated from your patient in regard to this particular body system.  Think here about what we learnt in lectures and labs about how you assess respiratory function and report on it.

Gastrointestinal System (GIT)

Again, subjective and objective data that you have accumulated from your patient in regard to this particular body system should be presented here. This about what the GIT system is and try and relate this to your particular patient. You may have been allocated to a surgical unit, your patient may have had a period of Nil by mount, alternatively they may have swallowing difficulties, these all need to be reported.  Again, think here about what we learnt in lectures and labs about how you assess GIT function and report on it.

Renal System

Present again subjective and objective data that you have accumulated from your patient in regard to this particular body system.  Think here about what we learnt in lectures and labs about how you assess renal function and report on it. Remember to consider all aspects of renal including how the patient voids as well as their fluid status.

Musculoskeletal System

How does the patient mobilize, here you should consider risk assessment are they a falls risk and what kind of assistance do they need?

Integumentary System

Think about the condition of the patient’s skin. Again, use the information from your risk assessment here. Are there any areas of concern, wounds, cuts pressure injuries, are these new?

Psychosocial Wellbeing

Consider the psychological state of your patient. Do they have any concerns in this domain?

Metabolic System

Metabolic refers to whether or not the patient is diabetic. If so you need to discuss again your subjective and objective data.

Additional systems

You can include additional headings referring to other body systems that are relevant to your patient such as haematology.

Medications

If your patient has a very long list of medications, you can present the complete list as an appendix and refer to any specific medications here.

(I don’t mind if you have medications here or in the patient introduction above)

 

Nursing Diagnosis

This is where you present your actual and potential diagnosis. Remember these are based on the data that you have gathered. In this section you need to structure both actual and potential nursing diagnosis using the North American Nursing Diagnosis Association’s Taxonomy of Nursing Diagnosis (NANDA). We discussed and developed these within each lecture throughout the semester (first year). There is a link to the Nursing Diagnosis textbook available on the LMS in the online resources tab. Remember an actual diagnosis reflects immediate and currently present signs and symptoms, while the potential diagnosis is based on risk factors that might develop into an actual problem for the patient.

Priority/Actual Problem One:  This is your actual nursing diagnosis. Consider how you identified this. Link it back to your data collection
NANDA statement linked to the above identified priority/actual problem
SMART Goal:  This is where you need to present you SMART goals you have identified to address the actual and potential nursing diagnosis. Remember that your SMART goals should be specific, measurable, achievable, realistic and time bound (SMART). Again, you need to link this back to the data that you collected in your initial assessment.  You should have one SMART goal for your actual nursing diagnosis and one SMART goal for your potential nursing diagnosis.
Independent Nursing Intervention Rationale and Supportive Evidence Expected Outcome (RUMBA format)
This is where you document information about the two interventions that you have implemented to address this priority/actual problem. You must include one (1) independent and one (1) collaborative nursing intervention to help resolve the patient’s actual problem. 

You can present these with sub heading and address each individually.

In this section you are encouraged to link back to the literature. Consider best practice guidelines.

 

Remember nursing interventions, those requiring a medical order are only to be discussed once for NURS90053 e.g. administration of medications, IV fluids.

Evidenced-based rationales with reference to the current literature are to be provided for each nursing intervention

 

For this to be successful please write your RUMBA statement (what you predict will occur as a consequence of your intervention, no more than one sentence)

 

 

 

 

 

 

RUMBA is useful to use here

Realistic

Unambiguous

Measurable Behavioural

Achievable

 

 

Collaborative Nursing Intervention Rationale and Supportive Evidence Expected Outcome (RUMBA format)
Please follow guidelines above for your collaborative intervention

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evidenced-based rationales with reference to the current literature are to be provided for each nursing intervention

 

For this to be successful please write your RUMBA statement (what you predict will occur as a consequence of your intervention, no more than one sentence)

 

Priority Problem Two:  This is your potential nursing diagnosis. Consider how you identified this and why is it a potential rather than an actual? Again, link it back to your data collection
NANDA statement linked to the above identified priority/actual problem
SMART Goal:
Collaborative Nursing Intervention Rationale and Supportive Evidence Expected Outcome (RUMBA format)
This is where you document information about the one intervention that you have implemented to address the potential problem. You must include one (1) collaborative intervention to help resolve the patient’s potential problem.

 

In this section you are encouraged to link back to the literature. Consider best practice guidelines. Do not include interventions requiring a medical order

 

Evidenced-based rationales with reference to the current literature are to be provided for each nursing intervention

 

For this to be successful please write your RUMBA statement (what you predict will occur as a consequence of your intervention, no more than one sentence)

 

 

 

 

Outcome of nursing and collaborative interventions

Here discuss the outcome of your chosen interventions and determine if what you set out to achieve in your RUMBA statement was successful. If not, why not? On reflection how did your chosen nursing interventions impact on the outcome.

 

Conclusion

Your conclusion provides you with an opportunity to summarise the assignment. Review your introduction and consider what it was you indicated here that you would discuss.

 

 

 

 

 

References

 

Remember to format your reference list in APA 7th ed style. This text is set out in the correct format for you. Please make sure that you start your reference list in a new page

 

You should be aiming for 10 – 15 sources for an essay of this size however it is important to use them well. I would prefer you to use 10 contemporary (no more than 5yrs old) sources, analyse these and show your understanding well than presenting a paper with 20 – 30 sources that you are unable to show your understanding or how these link to the patient or the care you have provided.

 

 

 

 

 

 

 

 

 

Appendix A: Place name of appendix here

Your appendices must start in a new page with each subsequent one starting on a new page. They must also be presented and named in order of appearance.  Please remember that appendices do not count towards the overall word count of the assignment. When referring to an appendix within the body of your essay please use the following terminology, please refer to Appendix (insert number or letter) for detailed information regarding…….

This first Appendix may relate to the medication list for the patient selected, if pertinent

Medication name (generic) Dose & Frequency Indication Adverse effects Patient education
         
         
         
         
         

Place your reference/s for your medication list here

 

Appendix B: Head-to-toe assessment guide for PEPAE

Place your completed Head-to-toe document here

 

 

Appendix C: Problem sheet template for PEPAE

Place your completed problem sheet here