SSESSMENT 1: Complex patient: plan of care and individual written report
Due: 27th April 2020 5pm
ASSESSMENT GUIDELINES
Your Patient Plan of Care is to be completed on the template provided on online. This is to be submitted with your individual written report as an appendix. An appendix goes at the end of the assignment, after the reference list.
There are two case studies provided – choose one of these case studies. That is, either Alice McCallum or Christopher Collins.
Nursing Care Plan Template
In the care plan template provided, identify 4-6 actual or potential physiological patient problems.
Identify all objective and subjective patient assessment data which supports your clinical reasoning in selecting these issues (i.e. how do you know that this is a problem for this patient?).
• This should be specific assessment data e.g. SBP 88mmHg instead of just saying ‘hypotensive’
Identify the optimal outcome that your patient should achieve before they are discharged.
• This should be a specific target that is appropriate for your specific patient e.g. SBP 110-130, urine output .5mls/kg/hr, GCS 15/15, etc.

Do not include nursing interventions in the template.
Problems may be:
• actual health problems: a health problem that is currently present or occurring and needs intervention to either end or reverse its effects. There will be patient signs and/or symptoms that support the manifestation of the problem.
Examples: Dehydration due to ........
Wound infection related to ......
Acute pain related to ....
Impaired skin integrity due to ....
Inadequate tissue perfusion related to……..
• potential health problems: a health problem which has not yet occurred, however based on assessment items there is a risk that the patient may develop this problem if no interventions or prevention measures are initiated.
The patient is ‘at risk of’ falls due to ...
The patient is ‘at risk of’ developing a DVT due to....
The patient is at risk of infection due to………
For potential health problems, please consider that you are identifying the risk based on evaluation of the data you have been given in the case study. As such, the assessment data will be what puts the patient at risk rather than the assessment data the patient would have if they had this problem as an actual problem. For example, the assessment data for an actual DVT will be redness, swelling, pain, heat while the assessment data for a potential DVT might be reduced mobility, low BP, activation of inflammatory response.
Focus on those problems and nursing/patient outcomes that nursing interventions could contribute to or could be completed during one standard nursing shift.
• Actual or potential problem Assessment data Nursing outcome
Actual problem: the patient is dehydrated related to decreased fluid intake • Low blood pressure (or ?BP) – SBP 88mmHg
• Tachycardia – HR 125bpm
• Patient states he is thirsty
• Dry mucous membranes
• Low urine output – 100mls in 6 hours • Patient will return to a normotensive state with a systolic BP between xx and xxmmHg
• HR will be between x and x
• Lack of reported thirst
• Moist mucous membranes evident.
• Urine output will be at least xmls/hr
The patient is ‘at risk of’ infection due to compromised host defences
• Low neutrophil count
• Receiving radiation therapy for cancer • Pt will remain free from any nosocomial infection
• WCC will remain between x and x
• Pt will verbalise how to prevent acquiring infections
• Pt’s family, friends, and hospital staff will use appropriate infection control include PPE and HH

Note: you can use common abbreviations or symbols, e.g. BP for blood pressure.
No marks are allocated to the template, however it is required to be submitted in order to receive a pass grade for this assessment.

Nursing Care Plan Report - 2000 words
From your nursing care plan template select 2 physiological problems. These may be actual problems, potential problems or one of each. Do not select psychosocial problems as you will not be able to discuss the pathophysiology of these.
For each of your chosen problems:
• Explain the pathophysiology and how this relates to the patients clinical presentation. I.e. What is happening in the body to cause the signs and symptoms that the patient has?
• Identify the key nursing interventions required specifically to treat or prevent the problem you have chosen. These interventions should be supported by contemporary clinical guidelines, policies and high quality best-practice evidence. Nursing interventions should include a rationale supported by evidence. Nursing interventions may be
o
? Independent interventions – nurse led, nurse initiated
? Collaborative interventions – with other members of the multidisciplinary team
? Dependant interventions - for example dependent on a doctors order
? These interventions should focus just on interventions which will specifically treat or prevent your chosen problems. Please do not include general nursing care which would be applicable here, or interventions which are required for all care (i.e. there is no need to identify obtaining consent, hand hygiene, etc. as this is required for all nursing interventions always). You do not need to describe the intervention, just state what you would do and why (not how you would do it).
• Identify the intended goals of care and patient outcomes for your problem, considering how you would evaluate this. I.e. what do you want to achieve for your patient specifically, how will you measure the patient’s progression towards this goal and how often will you take these measurements?
o
? Include specific outcomes here appropriate for your patient. The idea is that if someone were to read your plan of care without knowing the patient they would still be able to achieve patient specific goals. For example, your patient might have a history of COPD with CO2 retention and the target oxygen requirements would be 88-92%. Instead of your outcome being ‘satisfactory oxygen saturations’ you should specify ‘oxygen saturations of 88-92%’. Instead of saying “acceptable BP” as an outcome, identify what range you want the BP to be in for your patient.
As this is a formal academic report you should include
- an introduction: identify which patient case study you are using and the purpose/direction of your report e.g. -... This report will discuss compartment syndrome and surgical wound breakdown as two actual problems experienced by Mr. Smith. The pathophysiology of these conditions will be outlined along with nursing interventions required to treat these problems...-
- a conclusion: 1 or 2 sentences only which sum up your work. The conclusion should not include references as it is a summary of your ideas only.
- at a third year BN level, for a 2000 word report you should have at least 20 high quality sources of evidence
Referencing Tips
- moving away from Harvard to APA 7th for referencing. You may use either but you must be consistent within your assessment (i.e. not switch between the two, pick one or the other)
- Reference sources that you would be happy to have your care based off
- Do not use webMD, nurselabs, better heatlh channel, nursing blogs, nursing.com, Ausmed, nursebuff, scribd.com, wikipaedia, mygrandmasays.com. Do not use any sites where content is not peer reviewed. Do not use any sites which are selling products. Do not use any sites which have strong political motivation or backing (i.e. union based sites) as these are not high quality best practice sources.
- use international guidelines, national guidelines, clinical pathways, policy directives, uptodate, systematic reviews, and RCTs to base your clinical decisions on (RCTs should be used in combination with other higher level evidence).
- Always try to go back to primary research rather that referencing an article which is referencing an article which is referencing an article which is referencing the primary research as the meaning can be 'lost in translation'
Assessment 1 FAQ
Do the nursing diagnoses have to be based of the North America Nursing Diagnosis Association terminology? No, they can be but they don't have to be
Can my problem be medical? So long as it is within the scope of the RN to identify then yes
Can I chose a problem which is a symptom of my other chosen problem? no, you should be choosing 2 problems which are different, not one problem which is part of the same problem you have already discussed
Can I chose a problem which is an extension of the first problem? So long as these are two different diagnoses with 2 different physiologies then yes
My patient has sepsis and a wound infection/cannula. Are these 2 different problems? In these case studies no - in each case study the local infection has extended and turned into sepsis. The treatment of sepsis will also treat the local infection. You won't be able to discuss the pathophysiology and nursing interventions of these 2 as different problems, so these are the same problem in each of these case studies. You may chose one or the other, but not both.
huh? You can chose a broad medical diagnosis as 1 problem (eg. sepsis), or you can chose to do smaller components of this (eg. metabolic acidosis and hypovolaemia), but you cannot do a broad medical diagnosis and 1 symptom of the broad medical diagnosis - because if you chose, for example sepsis, then you would discuss metabolic acidosis and hypovolaemia as part of sepsis so your second problem cannot be part of the first problem. If you chose 2 smaller elements of a bigger problem, then you can discuss these, for example metabolic acidosis and hypovolaemia, without overlap/repeating the same concepts. It is up to you if you decide to do broader problems or smaller problems.
What do you mean 'an extension of the first problem'? I mean if one causes the other, but it is not the same thing, then you can use it (i.e. if the treatment and physiology is different), for example sepsis and risk of shock are different. However, sepsis and infection in this case would not be - because the patient is already sepsis from the infection so you would be treating the 2 things together.
Nope, I'm still confused: In these case studies the infection is no longer just an infection, it has spread and become sepsis. So you cannot chose sepsis and infection as these are 1 problem. If you chose sepsis this will also encompass hypovolaemia, fever, metabolic acidosis, respiratory distress as these are all part of the sepsis progression here. The pathophysiology and the treatment is the same – you cannot treat sepsis and not treat all of these things at the same time.
However, you can treat sepsis and not treat pain so pain would be separate. You can treat sepsis and not treat renal injury so this is different.
The risk of DVT/risk of pressure injury/risk of falls/risk of shock are all separate.
Is my patient in sepsis? yes
How do I know what to do about sepsis? https://www.sccm.org/SurvivingSepsisCampaign/Home
Does the word count include the care plan template? No, the 2000 words is just the report
Are references included in the word count? No
Should I use headings? It is easier for your marker if you use headings as this makes it easy to identify where you are discussing each aspect of the marking criteria. However you will not lose or gain marks if you do or do not use headings, this is up to you.
MARKING CRITERIA - Individual Written Report (weighting: 50%)
Criteria High Distinction ( 85%) Distinction (75-84%) Credit (65-74%) Pass (50-64%) Fail ( 50%)
Identification of 2 actual or potential health problems from the plan of care with evidence of correlation with assessment data and relevant pathophysiology. Plan of Care provided as an appendix (25%) Highly accurate and researched links made between assessment data, pathophysiology and the identification of health problems. Evidence of accuracy with researched links made between assessment data, pathophysiology and the identification of health problems. Evidence of researched links made between assessment data, pathophysiology and the identification of health problems. At times needs further detail or correlation. Limited development in the links made between assessment data, pathophysiology and the identification of health problems. However requires further research and needs greater detail or correlation. Lack of evidence of links made between assessment data, pathophysiology and the identification of health problems. Requires much further research and greater detail and/or demonstration of understanding.
Marks (/100) 21.5-25 19-21 16.5-18.5 12.5-16 0-12
Identification and development of appropriate rationalised nursing interventions. (20%) Interventions are appropriate and have a strong, well-researched rationale which demonstrates a high level of accuracy in data interpretation. Interventions are appropriate have research based rationales which demonstrates accuracy in data interpretation. Interventions are mostly appropriate and have research based rationales which demonstrates appropriate data interpretation. At times needed further depth and detail. The appropriateness of the intervention is variable. Rationales which demonstrate data interpretation. However work needs to demonstrate a greater depth of understanding and detail. Interventions are inappropriate or lack rationales such that data interpretation is not accurate.
Marks (/100) 17-20 15-16 13-14 10-12 0-9
Explanation of intended patient outcomes and how the effectiveness of the nursing interventions would be evaluated/measured (20%) Each intervention has a highly relevant and well researched expected outcome and the evaluation of this outcome is accurately discussed. Each intervention has a relevant and researched expected outcome and the evaluation of this outcome is discussed. Each intervention has a relevant, expected outcome and the measurement of this outcome is raised in discussion. Further explanation or detail is required at times. Interventions mostly have a relevant, expected outcome and the measurement of this outcome is raised in discussion. Much greater clarity and depth of understanding could be achieved. Interventions lack relevant, expected outcomes and/or the evaluation of this outcome is not raised in discussion. Much greater research and depth of understanding is required.
Marks (/100) 17-20 15-16 13-14 10-12 0-9
Depth of exploration of the topic(s): use of current and relevant sources of information to support the content elements (above). (20%) Evidence of sophisticated use of current literature from a variety of sources, incorporated effectively. Evidence of the use of current literature from a variety of sources, mostly incorporated effectively. Evidence of the use of literature from several differing sources. Further reading would enhance discussion points. Evidence of the use of literature, however scope is limited or not always current. Further reading from a wider variety of sources would enhance discussion points. Not enough use of literature evident. Further reading from a wider variety of sources is needed to enhance discussion points.
Marks (/100) 17-20 15-16 13-14 10-12 0-9
Academic writing: presentation; in-text referencing; reference list; grammatical structure of writing. (15%) Written expression is very clear with minimal to no grammatical errors made. The report has been structured clearly and the presentation/ referencing are in alignment with faculty guidelines. Written expression is clear with minimal grammatical errors made. The report has structure and the presentation/ referencing is in alignment with faculty guidelines. Written expression is mainly clear however some errors are evident. The report has some structure and the presentation/ referencing is mainly in alignment with faculty guidelines. Written expression at times is unclear with numerous grammatical errors made. The report requires further structure and the presentation and/or referencing is not in accordance with faculty guidelines. Written expression is unclear with many grammatical errors made. The report lacks structure and the presentation/ referencing is not in accordance with faculty guidelines.
Marks (/100) 13-15 11.5-12 10-11 7.5-9.5 0-7
Attached care plan template (pass/fail) Satisfactory (no marks awarded):
Care plan for patient is attached with 4-6 problems identified, associated patient assessment data and appropriate outcomes Unsatisfactory (no marks awarded):
Care plan not attached
Forum : FAQ
1. Q :
when discussing the assessment data in relation to the patient, can we refer to having a high temperature for example as pyrexia or are we to be specific like in the care plan with data?
A: t would improve clarity if you are specific - you could say the -patient is febrile to a temperature of xx.- Or you could say -evidenced by a temperature of xx- as you link this to the pathophysiolog
2. Q: Following on from my question about using sepsis and risk of septic shock. If I can use those two problems would it be ok that my interventions to resolve sepsis and prevent septic shock would be similar if not the same? I am just struggling to find any main interventions which aren't fluids, IVabx and source control, which would resolve the infection, hypovolemia and all knock on effects thus preventing septic shock

A:
Yes, the interventions to treat sepsis will prevent septic shock. So these interventions will be the same. You can structure your assessment differently here for ease of reading and to reduce your work count.
Pathophysiology of sepsis, and how this can present a risk of shock.
Interventions to treat sepsis, and identify which ones specifically will prevent shock. Also, include here any additional treatments you may need to consider to prevent shock (there are a few).
Outcomes to identify that sepsis has been treated, and what you would measure to ensure shock has not commenced.
As these are two separate problems but so closely related it makes sense to combine each section for this assessment, rather than doing patho 1, interventions 1, outcomes 1 and then patho 2, interventions 2 and outcomes 2.
3. Q: I understand I have to discuss the two problems, but in terms of interventions, how many you need. Is it ok to have 5 to discuss in the report ?
A: You should discuss the main interventions for the problem chosen. This will vary depending on what your chosen problem is. The interventions for sepsis, for example, should cover what is recommended for the immediate care of the patient in the surviving sepsis guidelines and the NSW health sepsis pathway. The interventions to prevent DVT will be far less. Your interventions do not need to cover general care for the patient not directly related to the problem (eg. washing, mouth care, updating family, hand hygiene for sepsis - these are all essential but not going to directly treat the sepsis. You will be doing this in real life, absolutely, but no need to discuss this in the assessment).
4. Q: I understand that our two chosen problems must be separate but can our 6 problems in the care plan be related e.g. phlebitis, sepsis, metabolic acidosis and hypovolaemia
A: I understand that our two chosen problems must be separate but can our 6 problems in the care plan be related e.g. phlebitis, sepsis, metabolic acidosis and hypovolaemia
5. Q: I'm a little confused on this section. Is this basically an extension of what we've put in the plan of care under 'Optimal Pt outcome/Goal'. Do we reference from BTF guidelines what recommended ranges the patient should be in? Is this section person opinion on what we identify the pt's outcome/goals should be?
A: es this is an extension of what is in the care plan template.
You need to identify what you are trying to achieve, what you will measure - what your target measurement is and how often you will measure this.
Take care when referencing the BTF as this is not a reference supporting what your vital sign ranges should be. This tool is used to determine when you need to escalate care. However, this is not specific to patients. This also says that you don't need to call for help until a SBP is 180, but we know that a SBP 150-170 is bad. We are not going to target a SBP of 170, and we are not going to target a HR of 120. BTF is not normal ranges, it is when to call for a clinical review etc.
Remember it needs to be specific for each patient. So if you have determined that your patients BP is inadequate due to his high lactate etc. then a target SBP of 100mmHg is not going to be adequate as this is still very close to what is currently is.
6. Q: Hello! I have a question regarding assessment 1. Is it reasonable to consider a local infection and a systemic infection as two distinct physiological problems? They are obviously closely interrelated, but do have separate physiologies and interventions.
A: In these case studies these are the same problem as the sepsis has originated from the localized infection. The sepsis is essentially an extension of the local infection, so you wont be able to talk about the pathophysiology and nursing interventions separately.
7. Q: was also wondering whether a problem related to tissue perfusion would be a separate problem to sepsis although they are related? As they may have separate focused interventions?
A: In this instance the tissue hypoperfusion is a result of the sepsis. So you can do tissue hypoperfusion as one problem, so long as sepsis is not your other problem - if you do sepsis and tissue hypoperfusion you will be saying the same thing twice. You need to say 2 different things.
Care Plan Template
PLAN OF CARE
PATIENT or NURSING ORIENTED PROBLEM OR PATIENT NEED PATIENT ASSESSMENT DATA OPTIMAL PATIENT OUTCOME or GOAL
Patient problem/issues/need - which is related to insert
Patient problems/issues/needs can be actual present and occurring now
Or potential when the patient is considered to be ‘at risk of’. As evidenced by (or how do we know this problem exists)
Objective patient data
Subjective patient data
Lab and other test results What do we (patient and nurse) want to achieve:
Specific, measurable, attainable, realistic and time orientated (SMART goals)

One row per problem
Up to 6 prioritised problems (minimum 4)
CASE STUDY: Theodore Selby
Location
Surgical ward
Introduction
Theodore, is a 54 year old, male who was diagnosed with early-stage osteoarthritis in the left knee, causing pain and affecting mobility. Surgery was planned to take weight/pressure off the damaged side of the knee joint and therefore relieve pain and also help improve joint function.
Theo was admitted for a left high tibia knee osteotomy 5 days ago. A plate and screws were used to stabilise the tibia as part of the procedure. Antibiotics were given by the anaesthetist on anaesthetic induction. He had an uneventful post-operative period and was discharged two days later. Chris was discharged with non-steroidal anti-inflammatory medication for pain relief, non-weight bearing on crutches and fitted for a supportive knee brace until his planned outpatient review in two weeks time.
Situation
This evening Theo re-presented at the ED. Complaining of pain at incision site, nausea and feeling shaky/shivery. Wound site left knee, sutured, skin appears ‘tight’, shiny and red. There are several small areas were dehiscence is evident with pus present. Oxygen therapy has been commenced.
Background
PMH: Osteoarthritis, asthma since child hood
Drugs: NSAID, Ventolin, Seretide accuhaler
Allergies: Nil known
Chris is a non-smoker and regular swims (3-4 times a week) and occasionally participates in kayaking.
Assessment/Observations:
A – patent
B – RR 29, Sp02 94% on 60% oxygen, equal air entry, nil adventitious sounds on auscultation, no mucous or sputum production, chest is clear. Verbal report of feeling breathless
C – HR 135, BP 98/57, cool peripheries, temp 38.9oC
D – GCS 15, PEARL. Patient states that he feels dizzy and ‘vague’. Pain score - left knee 7/10
E – Wound site left knee, sutures in situ, skin appears ‘tight’, swollen, shiny and red. Warm to touch. Several areas of dehiscence with pus present
F – IV cannula inserted
G - Glucose 5.1. Nil hx diabetes
Investigations & results
FBC – Hb 142g/l, WBC 18.4 x 109/L., Platelets 276 x 109/L.
U&E’s – U 5.4, Cr 78, Na 141, K 4.2, Glucose 5.1
CXR – normal
ABG – pH 7.25, PaCO2 21, PaO2 80, HCO3 18, BE – 4.0
Lactate – 5.3 mmols / L