Assignment: Clinical Case Report
Assignment: Clinical Case Report
Word limit: 2000 words
This assessment will consist of a clinical case report. The completed case report will need to be submitted via the Health of Older Adults (NURS 2024) course site Assessment 1: case report link by the assessment due date.
Relevance:
In order to plan and provide optimal person-centred nursing care, Registered Nurses need to be able to interpret clinical information and draw upon their knowledge of pathophysiology and evidencebased clinical practice. Therefore, the purpose of this assessment is to support the development of the skills needed to evaluate evidence and to develop reflection and clinical reasoning skills.
What you need to do:
Based upon the clinical scenario provided below, construct a case report. A case report is a detailed report of the client’s clinical presentation, nursing assessment, nursing diagnosis and nursing management plan. The case report will draw upon your knowledge of pathophysiology and relevant academic literature to support an evidence-based plan of care.
The case report must be presented using the headings provided below. A description of the content for each section of the report has been provided. It is important that all sections of the report are conceptually connected. For example, your knowledge of pathophysiology and your understanding of this particular client should underpin the nursing problems that you identify which should, in turn, drive the nursing management that is relevant for this clinical scenario.
Case Report:
The case report must include the following:
Introduction (1.25 marks) – 200 words
Introduce the client and provide a brief overview of their case. Provide an outline of the purpose and structure of the report.
You might like to think about the overview of the case study like a verbal clinical handover: what is the key information from the case scenario that would be relevant for the plan of care for this client?
Primary admission diagnosis (3.75 marks) – 300 words
Identify the primary diagnosis for the client (i.e. the reason the client was admitted to hospital). Provide a brief description of the pathophysiology and demonstrate how the presenting manifestations support the client’s primary diagnosis. Support this discussion using current literature (last 5 years).
Nursing problems (3.75 marks) – 300 words
Using your knowledge of pathophysiology and the manifestations, identify two (2) nursing problems that arise as a result of the client’s primary diagnosis. These problems may be actual or potential nursing problems. Provide a brief description for why these problems arise for this client. Support this discussion using current literature (last 5 years).
Nursing Management (6.25 marks) – 500 words
The nursing management must focus on the inpatient nursing assessment, nursing interventions and the role of the Registered Nurse (RN) related to medication management for this client and will address the two (2) identified nursing problems. Support this discussion using current literature (last 5 years).
This section of the report focuses on assessments and interventions that the Registered nurse conducts. So, avoid reverting to simple referrals to other members of the health care team – what does the nurse physically do to provide optimal person-centered care as part of the nursing management plan?
Nursing Problem 1: Nursing assessment, nursing intervention, medication management.
Discuss one (1) method of nursing assessment that would need to be performed related to the ongoing nursing management of this nursing problem. Provide a rationale for this type of assessment and briefly describe how this assessment would be conducted in this case.
Discuss one (1) nursing intervention that you would need to implement related to the ongoing nursing management of this nursing problem. Provide a rationale for the intervention.
Discuss the role of the RN in the medication management related to the ongoing nursing management of this nursing problem.
Nursing Problem 2: Nursing assessment, nursing intervention, medication management.
Discuss one (1) method of nursing assessment that would need to be performed related to this nursing problem. Provide a rationale for this type of assessment and briefly describe how this assessment would be conducted in this case.
Discuss one (1) nursing intervention that you would need to implement related to the ongoing nursing management of this nursing problem. Provide a rationale for the intervention.
Discuss the role of the RN in the medication management related to the ongoing nursing management of this nursing problem.
Discharge planning (6.25 marks) – 500 words
The discharge plan must focus on the multidisciplinary management for this client and will address the two (2) identified nursing problems.
Discuss the aim for discharge planning and the importance of using a multidisciplinary approach. Discuss the role of the Registered nurse to facilitate the multidisciplinary discharge plan for this client. Identify the members of the multidisciplinary health care team, and the role that they would play, specific to the two (2) identified nursing problems. Support this discussion using current literature (last 5 years).
Summary (1.25 marks) – 200 words
Summarise the major findings of this case report.
Referencing (1.25 marks)
The content of the case report must be supported through referencing of current literature and must include a reference list and intext citations. You will be assessed on referencing so make sure to follow the UniSA-Harvard referencing style closely to avoid losing marks.
Assignment: Clinical Case Report
Please refer to the Harvard Referencing System to accurately reference your case report: https://lo.unisa.edu.au/course/view.php?id=3839
Overall writing and presentation (1.25 marks)
This assignment must be saved as a word document. This case report must be structured using the headings provided and presented using academic writing. The use of dot-points will result in a reduction of marks. You will be assessed on the overall writing and presentation, so make sure that you follow the academic writing guidelines closely to avoid losing marks.
Please refer to the UniSA-School of Nursing and Midwifery academic writing guidelines to format your case report: https://lo.unisa.edu.au/mod/book/view.php?id=1478405&chapterid=204134
Clinical Scenario: Mrs Jessica George
Mrs Jessica George is a 79-year-old female living in rural South Australia with her husband of 60 years, Frank. Mrs George was diagnosed with Parkinson’s disease (PD) 15 years ago and she has been admitted to your ward at the Crystal Brook and District Hospital for respite care. Jessica’s mother died of pneumonia at the age of 80, having had PD for 30 years. She has nil other significant medical history. Jessica’s PD symptoms are being managed with Sinemet CR ® (200/50 mg tablets) every four hours during the day and Pramipexole 1.5mg daily. Frank, is her primary carer.
On general appearance, Jessica is alert and oriented but appears slightly anxious with a noticeable tremor in her upper limbs. During the assessment, it is noted that she has a ‘mask-like’ face and speaks in a hoarse, monotonous voice. Jessica’s physical exam reveals a heart rate of 82 with a regular rhythm, normal blood pressure (120/72) without orthostasis and a regular respiratory rate of 16. Jessica is able to arise from a chair without pushing off with her hands. A ‘drag/scuffing’ of the left foot is also noticeable, heard better than seen on ambulation. Her movements are slow and rigid and her balance appears to be unstable but uses no aids. She has had a recent fall at home, sustaining bruising and a skin tear to her left lateral lower leg. She also complains of constipation and a lack of appetite. It is also noted that she starts to cough when given a drink of water.
Frank informs you that Jessica is ‘very particular’ about taking her PD medications ‘on-time’. Jessica believes the effectiveness of her levodopa therapy starts to wear off after 4 hours. Jessica says that she has relatively little ‘good time’ and she alternates between a state of immobility, requiring assistance with activities of daily living (ADL), when the effect of the medication wears ‘off’, and a state of excessive, uncontrolled movements when the medication is in effect.
Jessica is being admitted to the ward for 5 days and will require specific nursing interventions to successfully manage her respite care.
Assignment: Clinical Case Report
Assignment: Clinical Case Report
How will I get assistance to complete this assessment?
Each of the topics delivered in this course will provide content that will give you the knowledge that you will need to successfully complete this assessment. For example, the weekly learning activities to develop the ISBAR plan of care will prepare you to complete the case report. You should make sure that you read all information provided, use opportunities to discuss this assessment in the weekly tutorials or virtual classrooms. In addition, the library will run a workshop (via virtual classroom) to support you to identify relevant sources of literature and the course coordinator will run a workshop (via virtual classroom) to support you to plan and write your case report. These workshops will be accessible via the NURS 2024 course site assessment folder.
Case Report Feedback and Results:
Feedback comments and grades will be provided using the Assessment Rubric and grades will be released via the assessment link within 10-15 working days.
Resubmission
Resubmissions will NOT be available for this assessment item.
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Assignment: Clinical Case Report
Assignment: Clinical Case Report
Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me:
Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
