Set the scene:
You are the new grad RN on nightshift in the acute medical unit. The patient was transfe
ed from the emergency department (ED) to the acute medical unit at 06:00 this morning. You have completed the first set of observations and assessments (recorded on the electronic charts attached).
Meet your patient:
Maria Smith, 79-year-old-female.
Maria presented to ED last night with worsening dyspnea, fatigue, dizziness and orthopnea for the past five days (5/7). The working diagnosis is suspected Heart Failure.
Maria takes levothyroxine 100mcg daily to treat Hashimoto’s, which she was diagnosed with in 1995, around the same time as her older sister. She takes perindopril 5mg daily to treat her hypertension, metformin XR 1000mg nocte to treat her type 2 diabetes mellitus and Crestor 5mg to treat her high cholesterol, which was diagnosed in 1998. Citalopram for depression. Maria had three elective caesarean sections in the 1970s and her gall bladder removed in 2005. Around the same time, she went through menopause and gave up smoking cigarettes. She reports no allergies to food or medication.
Maria lives at home with her elderly husband, Bill. Their youngest daughter, who lives nea
y,
ought Maria to the hospital as Bill called her and told her Maria was feeling crook. They manage the cooking and cleaning between themselves, but Maria admits she does it for the most part. She walks with her daughter three times per week but has not tolerated this in the past few weeks.
On appearance this morning, Maria sits upright in the bed, propped up on two pillows. She speaks to you in full sentences but reports feeling ‘puffed’ and having a ‘bothering cough’. Maria is using her accessory muscles to
eathe. However, she is alert and responds appropriately to all your questions. She is wo
ied about how Bill will cope at home without her.
The team has ordered Transthoracic echocardiogram and Chest x-ray today. The doctor has written a pathology order for Urea, creatinine and electrolytes (EUC), Full Blood count (FBC), Blood urea nitrogen (BUN), Liver function test (LFTs) and Thyroid stimulating hormone.
Assessment requirements digital presentation
Relevance
Nurses need to demonstrate effective and appropriate communication skills with clinical handover to provide high quality patient-centred care.
This assessment provides the opportunity to demonstrate your understanding of clinical handover, patient assessment and care planning.
Task instructions
Create a na
ated PowerPoint presentation of a clinical handover based on the clinical case scenario below. Your presentation should include
1. the ISBAR handover structure
2. Five evidence-based nursing recommendations for a plan of care
Look at all scenarios and files ECG file look at all
06:00hrs 12 lead ECG on a
ival to the ward:.
Suggested procedure
1. Review your course content and any extra materials on managing a patient with heart failure.
2. Read the clinical case scenario and electronic charts.
3. Formulate the ISBAR handover based on the case scenario, electronic charts chest auscultation and ECG. Create one slide for each component of the handover. ISBAR stands fo
· Introduce yourself & Identify the patient
· Explain the situation
· State the medical/surgical/psychosocial history
· Systematically state your assessment findings (use the A-H approach)
· Make recommendations for the patient care plan
4. Record your handover using PowerPoint (record your voice only). Support your five (5) nursing recommendations for the care plan with citations of evidence-based literature. Add a Reference list slide.
Presentation guidelines
Time: 5 minutes +/- 10% (30 seconds)
Submission:
Use the 'Turnitin' submission point to submit a MP4 file of your recording this should include PowerPoint slides with your voice embedded. Only a recording of a MP4 file will be accepted.
Referencing: use CDU APA 7th Referencing Style 2023 You must use scholarly sources each for your nursing recommendations. Do not use websites. You will be deducted marks in academic convention and argument. Minimum 5 references.
Support for this assignment
Research: contact a CDU li
arian for guidance. Review the content of the Nursing Libguides on the Li
ary website.
Academic Skills: contact a Language and Learning Advisor for support
)
co
ADULT(� 12 YEARS)
OBSERVATION CHART
Modifications in Use □ Date:
Neurological □
Obervations Required Time:
Write> 40 40
Respiratory Rate 35
(
eaths/ min) 30
( . )
25
20
If respiratory rate > 40 or 15
5 write value in box 10
Write< 5 5
02 Saturations (%) 98
(%)
96
94
XXXXXXXXXX
If 02 saturation < 88 90
write value in box Write< 88 88
0
2
Delivery Oxygen delivery mode
RA=Room Air NP=Nasal Prong �
HM=Hudson mask VM=Venturi Mask Oxygen flow rate
NRB=Non-Re-
eather HF=High flow (L per min/ FiO2)
Write> XXXXXXXXXX
Blood Pressure 190
(mmHG) 180
Score Systolic BP 170
160
t
150
140
I 130
(
I
)
120
I 110
I
100
90
' 80
70
If Systolic BP > 200 or 60
50 write value in box Write< 50 50
Write> XXXXXXXXXX
Heart Rate 130
(beats I min) 120
110
100
XXXXXXXXXX
80
70
If heart rate > 140 or 60
40 write value in box 50
Write< 40 40
Write> XXXXXXXXXXTemperature 38.5
( oc) 38.0
37.5
( . XXXXXXXXXX37.0 -
If temperature> 39.0 or
36.5
36.0
35.5 write value in box Write< XXXXXXXXXX
Urine Output ( • )
HPU < 6hrs / > 30 mis/hr
HNPU > 6hrs / < 30 mis/hr
Awake / alert
Level of Conscious
Asleep responds to stimuli
Easy to rouse
( . ) Cannot remain awake
Difficult to rouse
Pain Score
At Rest / With Activity
O None 10 Worst
lntervention(s)
Write Number
e.g. 1
Comments
Principal name
Other name(s)
D.O.B.
HRN
Sex
V
-- - -
V
- -- -
V
----
V
---
Page 1 of 6
Patient Label
Address must be documented if patient details hand written
V
----
V
----
V
V
---
I/
----
I/
----
I/
----
I/
IV
- - --
V
---
V
----
V
----
V
----
V
-- --
IV
I
;�
l
- - -
I/
Ii
Ii
l'
Show the trend: Plot t1
NP
4L
XX/XX
06:00
l
y
i
n
g
S
T
A
N
D
I
N
G
CASE STUDY FOR ISBAR
Maria Smith
4/254 President Avenue Sutherland NSW 2232
07/11/1944
HRN 222222
^
I
I
V
I
I
V
^
Principal name
Other name(s)
D.O.B. Patient Label
HRN
ADULT(� 12 YEARS) Sex
OBSERVATION CHART Address must be documented if patient details hand written
PIVC INSERTION RECORD
Instructions: The PIVC must have a VIP assessment and patency check a minimum of once per shift (i.e. 3 times in 24 hours).
For patency document Yes or No (Y or N). For VIP score refer to the guide below. For removal code refer to guide below.
Insertion Record Insertion Record
Date Inserted: Name: Date Inserted: Name:
Time Inserted: Signature: Time Inserted: Signature:
Insertion Site: Number of Attempts XXXXXXXXXXInsertion Site: Number of Attempts XXXXXXXXXX
Cannula Size: Reason: Cannula Size: Reason:
Date: Date:
Shift M L N M L N M L N M L N Shift M L N M L N M L N M L N
L y I I I I I I I I I I I V L y V V I V V V I I/ I V V VSign: Sign:
Removal Record Removal Record
Date I Time I Removal Code: Date I Time I Removal Code:
Name: I Signature: Name: I Signature:
Insertion Record Insertion Record
Date Inserted: Name: Date Inserted: Name:
Time Inserted: Signature: Time Inserted: Signature:
Insertion Site: Number of Attempts XXXXXXXXXXInsertion Site: Number of Attempts XXXXXXXXXX
Cannula Size: Reason: Cannula Size: Reason:
Date: Date:
Shift M L N M L N M L N M L N Shift M L N M L N M L N M L N
L ;y I I/ I I/ I I V V V I V V L 1cy I I V V I I I V V I I I
Sign: Sign:
Removal Record Removal Record
Date I Time I Removal Code: Date I Time I Removal Code:
Name: I Signature: Name: I Signature:
Visual Phlebitis Score
Observation
PIVC site appears healthy
1 of the following is evident
• Mild discomfort at IV site
• Mild Erythema at IV site
2 of the following is evident
• Discomfort at IV site
• Erythema
• Swelling (induration)
3 or more of the following are evident:
• Pain along path of cannula • Erythema
• Swelling I Pus/discharge
• Pyrexia (>37.8°C)
I 4 Severe local signs of Phlebitis
• Pain along path of cannula
• Erythema
• Swelling
• Palpable venous cord
• Pus/discharge Pyrexia (>37 .8°C)
Score
0
2
3
4
Management
No Signs of Phlebitis
Continue to observe and document every shift
Possible first signs of phlebitis
Continue to observe and document every shift
Early stages of phlebitis
• Remove and replace cannula to an alternate site
• Complete Riskman
Phlebitis
• Remove and replace cannula to an alternative site
• Send pus swabs for MC&S
• Commence wound chart
• Complete Riskman
____ ___;=======;;;;___,
Advance Stage of Phlebitis
• Immediate removal of cannula
• If pyrexic above 37 .8°C take blood cultures
• Send pus swab for MC&S
• Inform Medical Officer• Complete Riskman
• Commence Wound Chart
Page 6 of 6
PIVC Removal Codes
E
Removal@
72 hours
V
VIP Score
�2
B Blocked
Other,
0
Please
Document
Reason
D Dislodged
N
No Longer
Required
XX/XX/XX
XX:XX
L)ACF
18G
E.DELAHUNTY
TODAY
0
ED
Highlight
Maria Smith
4/254 President Avenue Sutherland NSW 2232
07/11/1944
HRN 222222
ADULT(� 12 YEARS)
OBSERVATION CHART
Principal name
Other name(s)
D.0.8.
HRN
Sex
Patient Label
Address must be documented if patient details hand written
Date:
T ime:
40
35
30
25
20
15
10
5
98
96
94
92
90
88
Wri te > 40
Write< 5
Wri te< 88
Oxygen delivery mode
Oxygen flow rate
(L per min/ FiO2)
200 Wri te > 200
XXXXXXXXXXi
XXXXXXXXXXI
XXXXXXXXXXi
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
130 - - -----
XXXXXXXXXX
XXXXXXXXXX
l XXXXXXXXXXl XXXXXXXXXX- XXXXXXXXXX1f XXXXXXXXXXt-----if---t XXXXXXXXXXif---t XXXXXXXXXX XXXXXXXXXX
90
80
70
60
50 Wri te< 50
XXXXXXXXXX XXXXXXXXXX XXXXXXXXXXt XXXXXXXXXXt XXXXXXXXXXt XXXXXXXXXX_ _ W_ri t_e_ >_14_0 _ _____.
XXXXXXXXXX XXXXXXXXXXl XXXXXXXXXXi XXXXXXXXXXl XXXXXXXXXXI XXXXXXXXXX XXXXXXXXXXi f---l-----l XXXXXXXXXXl--l XXXXXXXXXX XXXXXXXXXXl XXXXXXXXXXt XXXXXXXXXXI XXXXXXXXXX XXXXXXXXXXi
---+----+---+----
XXXXXXXXXX XXXXXXXXXXl XXXXXXXXXXl XXXXXXXXXXl----+-
XXXXXXXXXXI XXXXXXXXXX XXXXXXXXXXi
90
80
70
60
50
40 Wri te< 40
:! XXXXXXXXXX XXXXXXXXXX XXXXXXXXXXt XXXXXXXXXXt XXXXXXXXXX39_0 __ W_r_i t_e_>_3_9 _.0 _ ___.
;..._ XXXXXXXXXXl----l--+--l XXXXXXXXXXl XXXXXXXXXXt XXXXXXXXXXi XXXXXXXXXXI XXXXXXXXXX XXXXXXXXXXt
' XXXXXXXXXXl XXXXXXXXXX XXXXXXXXXXif---t XXXXXXXXXXt-----if XXXXXXXXXXt-----i XXXXXXXXXX XXXXXXXXXXt
' XXXXXXXXXXl XXXXXXXXXXl XXXXXXXXXX XXXXXXXXXXl XXXXXXXXXXt XXXXXXXXXXI XXXXXXXXXX ----------<
37.0 -------------------
----1---+--+----+----+---+ XXXXXXXXXXt XXXXXXXXXXil XXXXXXXXXXi--t XXXXXXXXXX -------
XXXXXXXXXX--+---l XXXXXXXXXXl XXXXXXXXXXt XXXXXXXXXXt XXXXXXXXXX XXXXXXXXXX
XXXXXXXXXX-
-
+--1--
XXXXXXXXXX-----+
--+---+--+--
1---+
-
---+-
XXXXXXXXXXf---+
-
-+-
-
-+ 35·5
--
W-r -i t
_
e_<_3
_
5
_
_
_
5_----i
he dot - join the line Page 2 of 6
HPU < 6 hrs / � 30 mis/hr
HNPU > 6 hrs / < 30 mis/hr
Awake / alert
Asleep responds to sti muli
Easy to rouse
Cannot remai n awake
Diffi cult to rouse
At Rest / Wi th Acti vi ty
0 = None 10 = Worst
Wri te Numbe
e .. 1
Principal name
Other name(s)
D.O.B. Patient Label
HRN
ADULT(� 12 YEARS)
OBSERVATION CHART
Sex
Address must be documented if patient details hand written
Modifications
(maximum duration 24 hours)
Respiratory Rate (
eaths / min)
RAT call ***
Clini cal review
No res onse
Start date & time
Duration
Si nature
0
2
Saturation(%)
ART call ***
Cli ni cal revi ew
No res onse
Start date & ti me
Durati on
Si nature
Blood Pressure mmHG
RRT call ***
Cli ni cal revi ew
No res onse
Start date & ti me
Durati on
Si nature
Heart Rate (beats/ min)
RRT call
Cli ni cal revi ew
No res onse
Start date & ti me
Duration
Si nature
Temperature ( 0c )
Cli ni cal revi ew
No res onse
Start date & ti me
Durati on
Si nature
Level of Conscious
RRT call ***
Cli nical revi ew
No res onse
Start date & ti me
Durati on
Si nature
Comments
Action Required
Rapid Response Team Call * * *
Response Criteria
• Any observation in a purple area
• 3 or more observati ons i n pink area at the same time
• You or fami ly members are wo
ied about the patient but