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Page 1 Faculty of Health Sciences Inquiry for Chronic Care Care Planning Rubric Levels of Achievement Criteria Unacceptable Needs Improvement Satisfactory Proficient Exceptional Nursing Problems 0...

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Page 1

Faculty of Health Sciences
Inquiry for Chronic Care
Care Planning Ru
ic

Levels of Achievement
Criteria Unacceptable Needs Improvement Satisfactory Proficient Exceptional
Nursing
Problems
0 Points
Not attempted/does not provide the
most important problems specific to
patient case scenario. Nursing
problems are not co
ectly
formulated as nursing diagnostic
statements.


2 Points
Limited understanding of
formulating nursing
diagnostic statements
specific to patient case
scenario.
4 Points
Satisfactory understanding of
formulating nursing diagnostic
statements specific to patient
case scenario. Some relevant
problems have been identified.
6 Points
Clear understanding of
formulating nursing
diagnostic statements
specific to patient case
scenario. Some relevant
problems have been
identified.
8 Points
Comprehensive
understanding of
formulating nursing
diagnostic statements
specific to patient case
scenario. Four of the
most important nursing
problems identified.
Expected
Outcomes
0 Points
Not attempted/does not provide
expected outcomes relevant to the
patient case scenario. Expected
outcomes do not adhere to SMART
guidelines.
1.5 Points
Limited understanding of
formulating expected
outcomes specific to patient
case scenario and adherence
to SMART guidelines.
3 Points
Satisfactory understanding of
formulating expected outcomes
specific to patient case scenario.
Expected outcomes mostly
adhere to SMART guidelines.
4.5 Points
Clear understanding of
formulating expected
outcomes specific to patient
case scenario and adherence
to SMART guidelines.

6 Points
Comprehensive
understanding of
formulating expected
outcomes specific to
patient case scenario
and adherence to
SMART guidelines.
Nursing
Interventions
0 Points
Not attempted/does not provide
nursing interventions relevant to the
patient case scenario. Interventions
do not adhere to the co
ect format
and do not include sufficient and
elevant detail.

2 Points
Limited understanding of
writing nursing
interventions. Interventions
do not adhere to the co
ect
format and relate to the
patient case scenario.
4 Points
Satisfactory understanding of
writing nursing interventions.
Interventions mostly adhere to
the co
ect format and relate to
the patient case scenario.
6 Points
Clear understanding of
writing nursing
interventions. All
interventions need to adhere
to the co
ect format and
elate to the patient case
scenario.
8 Points
Comprehensive
understanding of
writing nursing
interventions.
Interventions adhere to
the co
ect format and
elate to the patient case
scenario.
Scientific
Rationales
0 Points
Not attempted/does not provide
scientific rationales relevant to the
patient case scenario. Scientific
ationales are not supported by
appropriate reference.



2 Points
Limited understanding of
writing scientific rationales
elevant to the patient case
scenario. Limited use of
appropriate references to
support rationales.
4 Points
Satisfactory understanding of
writing scientific rationales.
Some rationales are relevant to
the patient case scenario and/or
supported by appropriate
eference.
6 Points
Clear understanding of
writing scientific rationales.
Most rationales are relevant
to the patient case scenario
and/or supported by
appropriate reference.
8 Points
Each rationale relates
to, supports and
provides validity for the
intervention. Each
ationale is supported
y appropriate
eference.
Page 2
Final Mark – 50% of marks for the unit
Handover of
Care
0 Points
Not attempted/does not provide
handover that adheres to iSoBAR
format.
1.5 Points
Limited understanding of
handover. Handover does
not adhere to iSoBAR
format or relate directly to
case scenario.
3 Points
Satisfactory understanding of
handover that adheres to
iSoBAR format. Handover
needs to relate directly to case
scenario and include all nursing
problems. Additional detail
equired.
4.5 Points
Clear understanding of
handover that adheres to
iSoBAR format. Additional
detail required.

6 Points
Comprehensive
understanding of
handover that adheres to
iSoBAR format.
Handover relates
directly to case scenario
and includes all nursing
problems.
Discharge
Plan
0 Points
Not attempted/does not provide
discharge plan.
1.5 Points
Limited understanding of
discharge planning.
Discharge plan does include
sufficient detail and/or does
not relate to case scenario.
3 Points
Satisfactory understanding of
discharge planning. Discharge
plan needs to relate directly to
case scenario and include all
nursing problems. Additional
detail required.
4.5 Points
Clear understanding of
discharge planning.
Additional detail required.
6 Points
Comprehensive and
detailed discharge plan.
Discharge plan relates
directly to case scenario
and includes all nursing
problems.
Referencing
according to
APA
guidelines
0 Points
No referencing according to APA
(6th edition) format AND/OR
contains content which
eached
academic integrity guidelines.

1 Points
Major e
ors in applying
APA (6th edition) format.
2 Points
Some e
ors in applying APA
(6th edition) format.
3 Points
Minor e
ors in applying
APA (6th edition) format.
4 Points
No e
ors in APA (6th
edition) format.
Formatting,
Paragraphing,
fluency and
clarity of
writing.
Adherence to
assignment
guidelines.
0 Points
Major e
ors in formatting, spelling,
and/or grammar. Language is
unclear and difficult to read
throughout the paper. Content does
not flow logically.
1 Points
Significant formatting,
spelling, and/or
grammatical e
ors.
Language is unclear in
places marking the paper
difficult to read. Content
does not flow logically.

2 Points
Some significant formatting,
spelling, and/or grammatical
e
ors. Language is unclear in
places, however no meaning is
lost. Content generally flows
logically.

3 Points
Minor occasional
formatting, spelling, and/or
grammatical e
ors. Clear
and effective language used
through most of the paper.
Content flows logically.

4 Points
Free or almost free from
formatting, spelling,
and/or grammatical
e
ors. Clear and
effective language used
throughout the paper.
Content flows logically.


1


Inquiry for Chronic Care
Care Planning
Assessment 2:
Case study: Heather Cook

You have commenced your clinical placement at Curtin Hospital on Ward 9A Medical Ward.
Following handover you have been allocated Heather Cook, aged 48 years, diagnosed with Multiple
Sclerosis. Heather was admitted earlier this afternoon to Ward 9A for management of her Stage 1
pressure injury.

You have been asked by your buddy nurse to write Heather’s care plan from admission to discharge.
Your buddy nurse completed the nursing assessment following Gordon’s Health Assessment
Framework which is provided below.

Using the Gordon’s Health Assessment Framework provided please complete a care plan for
Heather. Your care plan must include the following:

Nursing Problems:
Four of the most important nursing problems need to be identified and written appropriately as
nursing diagnostic statements.

Expected Outcomes:
You will need to write one expected outcome for each nursing diagnostic statement identified.

Nursing Interventions:
Four nursing interventions for each nursing diagnostic statement need to be identified.

Scientific Rationales:
One scientific rationale needs to be provided for each nursing intervention. Each rationale will relate
to, support and provide validity for the intervention. Each rationale is to be referenced.

Handover of Care:
You will need to include one handover of care using iSoBAR for the next shift.

Discharge Plan:
You will need to include one discharge plan for all identified nursing problems.


Please use the Care Planning template provided to set out your assignment.

Please refer to Assessment 2: Care Planning ru
ic.

The word count for this assessment is 2000 words



2
GORDON’S HEALTH ASSESSMENT: Heather Cook
Client Initials: H.C

Date of Birth: 10/2/1970

Marital Status: Ma
ied

Gender: Female

Ethnic Group: Anglo-Australian

Occupation: Nil.

Religion: Anglican

Education: Year 12

Primary Language: English

Usual Health Practitioner: Dr Kate Jones, Mary Street Practice, Perth

Additional notes:
Heather a
ived by ambulance from home with her husband in attendance. Heather was diagnosed
with MS when she was 30. On initial examination Heather has noticeable non-blanchable redness over
her right ischial tuberosity. Skin intact. Long term IDC insitu. Requires hoist for transfe
ing.

CHILDHOOD / ADULT ILLNESSES
Measles Hypertension Mumps Jaundice
Diabetes Pneumonia STD Tuberculosis
Cystitis Chickenpox √ Anaemia Scarlet fever
Heart
Disease
Hepatitis A / B / C Whooping
Cough


Rheumatic
Feve
Rubella
Additional notes:

Diagnosis of MS 2000
Chickenpox – 3 years old - no sequelae.

IMMUNIZATIONS
Diphtheria √ Smallpox Measles √ Polio √
Rubella √ Mumps √ Tetanus Tuberculin
test

Cholera Typhoid Hep A / B √
HOSPITALIZATIONS
Multiple presentations. Refer to medical records.

ACCIDENTS / INJURIES
Nil previous accidents/injuries noted or voiced.
3
DRUG REACTIONS
Patient states she in unaware of any drug reactions.
ALLERGIES
Nil known.
CURRENT MEDICATIONS
Baclofen oral tablet 20mg QID
Ditropan (extended-release) oral tablet 10mg OD

Paracetamol 1g orally 4-6/24 PRN for pain.
DEVELOPMENTAL DATA
Only child. Parents divorced
Answered Same Day Oct 06, 2020

Solution

Sheenu answered on Oct 08 2020
149 Votes
Nursing Diagnostic statement 1 : Impaired skin integrity (NANDA, 2014) related to stage 1 pressure injury as evidence by noticeable non- blanchable redness over Right ischial tuberosity.
Expected outcome: Heather will demonstrate improve skin integrity as evidence by no redness over right ischial tuberosity, absence of pain and i
itation within a week.
Nursing Intervention 1: Nurses will assess the patient skin integrity using the Brandon scale.
Rationale 1: the studies have identified that Brandon scale is the significant part of the risk assessment and prevention of pressure injuries (Noonan, Quigley, & Curley, 2011).
Nursing Intervention 2 : Nurses will clean the skin and keep dry 24 hours.
Rationale 2: The study also identifies that Necrotic tissue can serve as the nidus for the infection and colonization of the bacteria that could result in prolonging the wound healing (Jaul, 2010). Cleansing the skin will help in keeping the skin clean and preventing infection
Nursing intervention 3: Nurses will reposition Heather 3/24
Rationale 3
This will help in providing the relief from the pressure, which is also the most common conservative treatment for the pressure ulcers (Kruger et al, 2013). This will help in providing the relief from the pressure, which is also the most common conservative treatment for the pressure ulcers (Kruger et al, 2013).
Nursing intervention 4: Nurses will assess the wound dressing as PRN
Rational 4: Study conducted by Agrawal & Chauhan (2012), removal of the devitalized tissues is very important for granulation and accurate staging of the wound. Therefore, keeping intact the skin integrity and de
idement are essential for the patient.
Nursing diagnostic 2: Acute pain (NANDA, 2014) related to stage one pressure injury as evidence by pain score of 7/10, Heather states” my bottom has becoming increasingly sore over the last week, especially on the right side”. Heather said “it really hurts if I sit for too long in my wheelchair”.
Expected outcomes: Heather will demonstrate pain score of 0/10 in 30 minutes.
Nursing intervention 1: Nurses will assess pain score of heather 4/24
Rational 1: Assessing the pain score of the patient is significant for understanding the level of discomfort that patient is experiencing (Baharuddin et al, 2010). Assessing he pain score has also ben identified as the major intervention in the emergency department for conducting the comprehensive pain management (Baharuddin et al 2010).

Nursing intervention 2: Nurses will administer paracetamol to heather, PRN
Rational 2: According to the study of Esh, et al (2017) paracetamol can be considered as the appropriate medication for the management of the moderate to severe pain. It is also appropriate for the patient with adjunctive opioid analgesics and also reduces the fever. The studies have also identified that paracetamol is devoid of the side effects which could commonly occur in the case of using the nonsteroidal anti-inflammatory drugs (Remy, Ma
et, & Bonnet, 2006).
Nursing Intervention 3: The non-pharmacological techniques of pain management will be used.
Rationale 3: Some of the common non-pharmacological pain management techniques include massage, relaxation therapy, distraction and positioning. The studies have identified that the use of noninvasive pain relief or the non-pharmacological pain management techniques can help in increasing the release of endorphins and can also enhance the therapeutic effects of pain relief medications (Pak et al, 2015).
Nursing Intervention 4: Nurse will evaluate the effectiveness of the pain control measures by conducting the ongoing assessment of the patient.
Rational 4: Dansie, & Turk, (2013) have...
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