Subject Code : 10191FoundationsforProfessionalPractice2
10191 Foundations for Professional Practice 2 Patricia Green Case Study Nursing Assessment Answer
Assessment Task:

Case:
You arrive to your placement shift on a surgical ward and attend the morning handover. In this scenario, you are the student nurse working with the Registered Nurse assigned to looking after the patient Trish this morning. You listen to the following handover: Patricia (Trish) Green is a 45-year-old female. She is the mother of Lucy, aged 20 and Ella, aged 16. Trish has a partner Steve, although he is not the father of her children. Trish’s ex-husband (and the girl’s father) Adrian also lives in Canberra. Lucy lives a few suburbs away with her boyfriend. Ella is in year 10 of high school and splits her time 50/50 between living with Trish and Adrian.

Trish turned to sex work after meeting her friend Anne (also a sex worker) at a local women’s group. Trish has now been sex-working for the past 2 years. She is happy with this arrangement as sex work pays better than other jobs, and she can work around Ella’s schedule which provides the autonomy and flexibility she needs. Her children are not aware of her sex work. They think she is an aged-care support worker. Trish has regular clients who are respectful and who pay generously.
Trish is otherwise in good health. She has very little past medical history aside from a tonsillectomy when she was 10 years of age, uterine fibroids after having Ella and a
fractured ankle sustained in a skiing accident two years ago. Trish was admitted to hospital 3 days ago following a diagnosis of appendicitis. Trish underwent an emergency appendectomy 2 days ago. There have been no apparent complications post-operatively. The morning handover informs you that Trish had been mobilizing independently around the ward yesterday and requires minimal assistance with self-care activities. Yesterday she has been eating and drinking moderate amounts. She has been receiving regular oral analgesia during the day. She slept soundly overnight, so the nursing staff report they did not disturb her. Her 0600 vital signs were: Temperature 36.3, RR 13, HR 112, BP 114/72 (normal SBP 122). She has not yet had her bowels opened post-operatively. After handover, you enter Trish’s room. You notice that Trish winces as she moves from sitting to lying. You introduce your self and ask her how she is feeling. Trish states, ‘I feel a bit ordinary today actually, my tummy is pretty tender, maybe 6//10 on that scale you use’.

Task:
1. Based on the case information and clinical documentation (Canvas), you are required to analyse the clinical case study and develop a nursing plan of care.
When preparing your nursing plan of care, include the following:
• Briefly outline the context of the case in the present moment.
• Identify and analyse the clinical data that informs a primary clinical assessment (ABCDE).

• Based on this analysis what judgments (hypothesis, overall impressions) can be made?
• Identify what integrated person-centered (physical and non-physical) assessments are required during your shift, based on the case. Support your chosen assessments
with evidence from the literature.
• Identify 3 clinical priorities for the immediate care of the patient. Support each choice of priority with a brief rationale using appropriate evidence from the literature.
• Outline your plan of care to address these priorities and how you will evaluate them. Support your discussion with evidence from the literature.

Plan of care structure:
• The nursing care plan is to be presented professionally as a clinical case report. A template will be provided on Canvas to ensure clear articulation.
• The submission must be expressed clearly and succinctly with correct grammatical expression, spelling and logical flow. Refer to the APA Publication Manual (see supportive resources) and/or seek assistance from Study Skills as required for academic writing support.
• You may submit your care plan in electronic format via a word document (.doc or .docx).
• Standard formatting (APA 6th edition) – double line spacing, Times New Roman font size 12, includes a header or footer with your student ID number.
• Use a variety of credible and recent sources to support the development of your care plan and summary. References should be less than 10 years old. You may include
clinical guidelines, practice standards, and peer-reviewed manuscripts.
• APA (6th edition) referencing style must be used and a reference list included.

 

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