Med-surgical case study, NRSG370 Assessment

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• Refer to the stages of the clinical reasoning cycle
• Clearly identifies and prioritises 3 relevant nursing issues/problem
• the case study essay focus has been addressed and discussed as per clinical reasoning cycle
• the case study essay content has clear links to contemporary nursing practice of the clinical elective area and discusses the provision of ethical, legal, evidence-based, holistic person-centred care, including the establishment of realistic and relevant goals
• the case study paper demonstrates a depth of understanding of the topic and significant issues as per scenario and clinical elective area.

Case study instructions:
Utilise the Clinical Reasoning Cycle (Levett-Jones, 2013) (a clinical decision making
framework) to plan and evaluate person-centred care:
1. Considering the person’s situation, collect, process and present related health information;
2. Identify and prioritise at least three (3) nursing problems/issues based on the health assessment data that you have identified for the person at the centre of care;
3. Establish goals for priority of nursing care as related to the nursing problem/issues identified;
4. Discuss the nursing care of the person, link it to assessment data and history;
5. Evaluate your nursing care strategies to justify the nursing care provided;
6. Reflect on the person’s outcomes.
NRSG370 Assessment Task 3 – Case Study Details:
Bianca Lane, 20, Peritonitis following ruptured appendix Medical/Surgical #1
Ms. Bianca Lane presented to the Emergency department with a history of 2-3 days of severe Right Lower Quadrant abdominal pain, lack of appetite, nausea and fever.
She has a past medical history of asthma and depression, with her current prescribed and compliant medications list which includes:
• Salbutamol
• Seretide
• Sertraline
Physical examination of the abdomen and an ultra-sound diagnosed a perforated appendix, which required emergency laparoscopic surgery. Bianca is now 36 hours post-operative and her observations are as follows:
• BP 94/45mmHg
• HR 136
• Temp 38.5°Celcius
• RR 24/min and shallow
• SpO2 95% on room air
She has been complaining of increasing nausea, feeling ‘bloated’ and increasing centralised abdominal pain, that is worse with any movement and respiration, giving it a score of 7/10.
Physical examination identifies a distended rigid abdomen, with generalised abdominal guarding and no bowel sounds.
To investigate her condition further, a FBC, electrolytes, blood cultures and an abdominal X-ray were organised. Pathology results reveal a raised white blood cell (WBC) count and CRP, blood cultures are pending. Abdominal X-ray identifies oedematous and gaseous distention of the small and large bowel.
You are the RN caring for Bianca post-operatively on the surgical ward.
References:
Levett-Jones, T. (Ed.), (2013). Clinical reasoning: Learning to think like a nurse. Sydney, Australia: Pearson Education.

Criterion Referenced Rubric: Supplimentary Assessment, Case Study

Criteria for marking
High Distinction
(95-100%)
High Distinction
(85-94%)
Distinction
(75-84%)
Credit
(65-74%)
Pass
(50-64%)
Unsatisfactory
(31-49%)
Unsatisfactory
(0-30%)
Sequencing
5% The content in the case study directly matches the outline presented in the introductory paragraph. The case study ends with a rational conclusion. The content in the case study comprehensively matches the outline presented in the introductory paragraph. The case study ends with a rational conclusion. The content in the case study thoroughly matches the outline presented in the introductory paragraph and the case study ends with a rational conclusion. The content in the case study matches the outline presented in the introductory paragraph. and the case study ends with a rational conclusion. The content in the case study mostly matches the outline presented in the introductory paragraph and the case study ends with a conclusion. There is a clear introduction, followed by the body of the case study, with a conclusion. However, content within the body and within paragraphs is not always logically sequenced. There is no clear introduction, body and/or conclusion. There is no sequencing evident.
Content

50% Extensively defines and discusses the provision of ethical, legal, evidence-based, holistic person-centred care, including the establishment of realistic and relevant goals.
Includes relevant discussion on the collection, processing and presentation of client/patient information.
Clearly identifies and prioritises 3 relevant nursing issues/ problems.
Strong evidence of use and understanding of the clinical reasoning cycle. Comprehensively defines and discusses the provision of ethical, legal, evidence-based, holistic person-centred care, including the establishment of realistic and relevant goals.
Includes relevant discussion on the collection, processing and presentation of client/patient information.
Clearly identifies and prioritises 3 relevant nursing issues/ problems.
Clear evidence of use and understanding of the clinical reasoning cycle. Thoroughly defines and discusses the provision of ethical, legal, evidence-based, holistic person-centred care, including the establishment of realistic and relevant goals
Includes discussion of the collection, processing and presentation of client/patient information.
Clearly identifies and prioritises 3 relevant nursing issues/ problems.
Evidence of use and understanding of the clinical reasoning cycle. Defines and describes the provision of ethical, legal, evidence-based, holistic person-centred care, including the establishment of relevant goals
Includes the collection, processing and presentation of client/patient information.
Identifies and prioritises 2-3 relevant nursing issues/ problems.
Some evidence of use and understanding of the clinical reasoning cycle. Describes the provision of ethical, legal, evidence-based, holistic person-centred care, but does not provide clear rationale for choices or the establishment of relevant goals
Discusses the collection, processing and presentation of client/patient information.
Issues/problems identified are unclear or not relevant to the case study. Minimal evidence of use and understanding of the clinical reasoning cycle. Limited evidence of the consideration or provision of ethical, legal, evidence-based, holistic person-centred care,
issues/problems identified are not relevant to the case study or poorly prioritised or key issues/problems have been omitted.
No evidence of use and understanding of the clinical reasoning cycle No evidence of the consideration or provision of ethical, legal, evidence-based, holistic person centred care,
No issues/problems identified.
No evidence of use and understanding of the clinical reasoning cycle

Critical thinking, reasoning and evaluation of evidence

30% There is evidence of comprehensive depth and breadth of reading. A concise and well supported analysis related to nursing care and issues/problems is presented, and is supported by adequate and appropriate evidence. There is evidence of detailed depth and breadth of reading. A concise and well supported analysis related to nursing care and issues/problems is presented, and is supported by adequate and appropriate evidence. There is evidence of both depth and breadth of reading. An analysis is presented related to nursing care and issues/problems, and is supported by appropriate evidence. An analysis is presented related to nursing care and issues/problems supported by evidence. There is evidence of supportive reading An analysis is presented related to nursing care and issues/problems with minimal supportive evidence Minimal analysis is presented related to nursing care and issues and/or analysis presented lacks relevance to the topic. Little to no analysis is presented related to nursing care and issues
Paragraph, structure / intelligibility

5% Flawless presentation of ideas. The writing is organised into paragraphs that are structured well, and the information is organised appropriately within the paragraph. Each paragraph relates to a discrete idea. There are clear linking sentences that link each paragraph to the next consistently. The writing is organised into paragraphs, and the information is organised consistently and appropriately within the paragraph. Each paragraph relates to a discrete idea. There are clear linking sentences that link most paragraphs to the next. The writing is organised into paragraphs, and the information is organised appropriately within the paragraph. Most paragraphs relates to a discrete idea. There are clear linking sentences that link most paragraphs to the next. The writing is organised into paragraphs, and the information is mostly organised appropriately within the paragraph. Most paragraphs relates to a discrete idea. The paragraphs mostly link to one another. There is evidence of paragraphs, however paragraph structure is disorganised, with no clear ideas, and no links. Some evidence of paragraphs, however paragraph structure is disorganised, with no clear ideas, and no links.
Sources & Referencing

10% Credible and relevant references are used. Accurate use of APA referencing style in all instances. A broad range of in-text citations has been used.
Credible and relevant references are used. Accurate use of APA referencing style in all instances. A range of in-text citations has been used.
Credible and relevant references are used. APA referencing style is almost always accurate. A range of in-text citations has been used. Credible and relevant references are used. APA referencing style is accurate on most occasions. There is limited use of a range of in-text citation formats. Credible and relevant references are used. APA referencing style is demonstrated inconsistently. There is no variation of in-text citation format. Not all references are credible and/or relevant. There are inaccuracies with the APA referencing style. There may be an overuse of direct quotations. Not all references are credible and/or relevant. There are several inaccuracies with the APA referencing style. There may be an overuse of direct quotations.

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