Background
Advanced patient assessment skills are essential for the specialty nurse to extract accurate and succinct patient information, identify patient problems and develop a plan of care. Critical care nursing is complex and requires critical thinking to prioritise patient problems and interventions.
Clinical priorities are the most important pressing patient problems or issues based on the assessment data collected. The primary and secondary survey, patient history and the head to toe physical examination approaches provide a structured and practical framework of assessment and prioritisation in acute care situations, breaking down a complex clinical situation into more manageable parts.
Task Description
This patient should be considered `complex` on the day of assessment for one or more of the following reasons:
The patient had multiple body systems affected by their illness
The patient`s care was complicated by psychosocial factor
The patient`s care had to be escalated
Care provided to the patient was not consistent with current guidelines.
Complete a comprehensive assessment on this patient
This specific patient assessment will form the basis for your assignment submission.
Identify the priority problems for this patient based on your assessment and the patient`s underlying health condition
Select three of the highest priority problems identified and develop a best practice plan of care that clearly identifies and describes key nursing goals and interventions to effectively manage these priority problems. In your plan of care, you should use evidence-based guidelines and research to inform and justify your nursing interventions.
Critically appraise the actual nursing care provided for one of the problems you have identified in your nursing care plan and make recommendations for future nursing practice based on your findings.
Part
1. Written handover (this item will not be included in the word count for this assignment)
In consultation with your Clinical Nurse Educator, select a patient admitted into your unit and:
1. Conduct a structured patient assessment.
2. Provide a brief summary of the patient`s presenting problem and document your de-identified patient assessment data using the Handover template provided. Add this document as an appendix to your written paper. This document will not contribute to the word count for this paper.
2. Patient care plan and evaluation of care
1. Demonstrate your knowledge of best practice specialist nursing care:
I. To decide what high priority problems to discuss you should consider what you are most concerned about for this patient based on your assessment findings.
II. Your selection of problems will indicate your ability to prioritise patient problems in the clinical setting. E.g. nutrition might be a high priority problem for one patient, but in another who is on multiple inotropes, invasive ventilation with inhaled nitric oxide and copious secretions, it is likely to be a lower priority despite being very important.
III. Discuss why your selected problems are high priority problems for this patient based on the underlying clinical condition and data presented in your handover
2. Demonstrate critical thinking and evaluation skills
Select one of your high priority, actual patient health problems, and critically appraise the actual nursing care provided in relation to this problem for your selected patient.
I. How was this high priority problem managed and how does the management relate to best practice as presented in your plan of care?
II. What are your recommendations for future nursing practice based on your findings?
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