15 Jul THERE IS TO BE A BRIEF INTRODUCTION WHICH INCLUDES THE PATIENT’S PRESENTING PROBLEM AND MEDICAL DIAGNOSIS, CO-MORBIDITIES AND CURRENT MEDICATIONS.
The situation: There is to be a brief introduction which includes the patient’s presenting problem and medical diagnosis, co-morbidities and current medications. This introduction also situates the patient in relation to the type of clinical setting where the student cared for the patient, when the student conducted the assessment in relation to the illness, and the timeframe for the care plan. Current medications may be presented as a table including generic and trade names, patient’s dosage and the indication for that patient. (approximately 200 words)
Collect cues: The patient is then assessed by the student at the time of care, using the DETECT framework. This is to be an assessment that you conduct, not a copy of someone else’s assessment. It can include medical test result available at the time of the assessment
A – Airway
B – Breathing
C – Circulation
D – Disability
E – Exposure
F – Fluids
G – Glucose
Process information: Assessment findings and abnormalities are to be discussed in relation to the underlying pathophysiology of the causal disease process or processes, and the patient’s signs and symptoms.
Note: Pathophysiology means changes in physiological function related to disease; it does NOT relate only to blood test results. (approximately 500 words)
Identify problems (Three nursing diagnoses): From the assessment the three (3) highest priority nursing diagnoses (problems or potential problems) relevant at the time of the assessment are identified with causative statements and evidence criteria. (approximately 150 words)
Set Goals for the identified problems: For each identified nursing diagnosis/problem there is at least one nursing goal that meets SMART criteria. (approximately 150 words). SMART-specific, measurable, attainable, measurable, realistic, time bounded.
Plan Action: Discuss a plan of nursing care for the patient at the time you are caring for them that addresses the identified nursing diagnoses/problems. The planned nursing interventions should be detailed and supported by rationales. This may include nursing management of ordered medical therapies, such as medication and fluid management.
Rationales should be provided for each nursing intervention and each should be supported by reference to nursing research, science and best practice literature. (should be presented as discussion – approximately 1000 words)
Evaluate outcomes: The patient’s outcome should be evaluated in relation to the set nursing goals. This evaluation should be a realistic evaluation of the patient’s progress towards the set goals during the time that you were involved in the patient’s care, including re-evaluation against the set outcome criteria. (approximately 200 words)
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