Assessment 2Submit via Case Study Turnitin link via Blackboard site under ‘Assessments’ tabUnit Learning • Develop an appropriate response to the acute nursing needs of a diverse range ofOutcomes for this clients.assessment • Utilise evidence based practice to identify and problem solve the needs of patientsin acute situations.
Assessment InstructionsKelly Malone is a 49 year old female who has a history of ‘not being able to breathe well through her nose’ , and this disrupts her sleep. Kelly also states that if she exercises or exerts herself, she ‘cannot get enough air in’ and has to mouth-breathe, using breathing techniques to take deep, slow breaths to stabilise her breathing pattern, so that she does not go dizzy. Kelly has a history of sensitivity to codeine (which causes nausea, dizziness, temperature flushes and malaise), is not on any medication, and has no other medical problems.After review by the specialist ENT surgeon, it was arranged for Kelly to undergo surgery for a septoplasty and right ethmoidectomy. On arrival pre-operatively Kelly’s observations were: T-36.40C, HR-69bpm, RR-18pm, BP119/70mmHg, 02-94% RAYou are looking after Kelly on her return to the ward post-operatively at 11:30hrs. She is awake and alert, and has a nasal bolster under her nose, with moderate sanguineous ooze. Her current observations are: T-36.20C, HR-68bpm, RR-18pm, BP-111/73mmHg, 02-93% RA, and pain score 2/10. IV Compound Sodium Lactate IL is running at 4/24 rate into Kelly’s left arm. Kelly’s anaesthetist has prescribed Paracetamol lg IV/PO 6 hourly, Celecoxib 200mg PO BD, and Tramadol SR 100mg PO BD. Assume nothing, if data is not stated, you should state that it is not known or information has not been provided, and advise what actions you would take.You are required to research and write an essay with headings, directly relating to the above scenario. Using the nursing process, outline the nursing management for Kelly post-surgery (using all headings in the assignment criteria), discussing all care in general, but focussing on three (3) priority nursing diagnosis/ problems. Please review Learning material/ Module 1/ Nursing process for lecture material that students have been given, regarding the nursing process and plan of care.Presentation e Format in accordance with School of Nursing & Midwifery guidelines (see BB Assessment tab).e Academic writing style.e Appropriate sentence structure, grammar and spelling.Logical flow.Introduction (100-150 words)• A general overview of the topic and definition of terminologyAn outline of the paperBod of essa Background of condition (200 words)• From the information given above, and general information about the condition.• This should be given as an iSoBAR handover.Do not assume or make up anything — if information is missing, state that it is missing, and state what you would need to do, and what information you would need to collect.Management (1000-1200 words)Using the nursing process, outline the nursing management for Kelly post-surgery, discussing all care in general, but focussing on three (3) priority nursing diagnosis/ problems.Students should include their three (3) prioritised nursing problems into a table as an appendix (eg into a nursing care plan) to show your use of the nursing process. Students may also include their assessment data/ list of actual and potential nursing problems into tables as appendices if they wish. Ensure that each part of the nursing process is discussed within the essay as well, with enough depth to show coverage of each section. Within the essay refer to the appendices in all of the appropriate places. See sample nursing care plan that has been provided.Assessment – Students should demonstrate that they have looked at all of the assessment data (considering all body system assessments, and also considering how functional health patterns/ 12 ADLs are affected). Students are not to assume or make up assessment findings. Discuss the assessment findings that have been given, what other assessments would be done, what appropriate assessment tools (eg Falls Risk, Braden Scale and Pain Assessment) would be used, and if any findings are not within normal parameters, students should identify this and give a rationale why this is so.Nursinq diaqnosis – After analysing all of the assessment data and patient’s responses that students have gathered above, students should develop a list of actual and potential nursing problems/ issues (this may be put into an appendix to save word count). From this list students would choose three (3) prioritised nursing diagnoses to discuss in-depth (focus should now be post-operative). Students need to demonstrate why they have prioritised these three (eg use of triage’s primary survey, use of first-aid DRSABCD, actual v potential, etc) —this should demonstrate the student’s ability to prioritise, not just choosing three that they want to discuss.Planninq – Students should demonstrate their planning of care with SMART goals (specific, measurable, achievable, realistic, and with timeframe), advising of planned outcomes and criteria that are required. Includes psychosocial outcomes. The patient should also be involved in identifying planned outcomes.Implementations – Interventions and actions taken to meet the planned outcomes and achieve the SMART goals. This can be nursing interventions, referral to multidisciplinary team (nurse needs to ensure multidisciplinary team member has followed up). Each intervention should include the rationale why this intervention is being done and supported by evidence (reference). This also includes documentation in all areas required (which will become measured criteria from SMART goal as evidence in evaluation).Evaluation – Evaluation of planned goals occurs throughout the nursing process, but is discussed at the end. Students should demonstrate whether planned outcomes and goals were met (or not), if not then why have they not been met, and whether re-evaluation is required at a later date. Students need to demonstrate how they know whether planned outcomes have been met, what tools were used, where this is documented, and what is the evidence that goals have been met (usually documentation as evidence). Post-operative education (200 words)Outline
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