Reference no: EM133059436

NURS90130 Nursing Assessment and Care - The University of Melbourne

Assessment Task: Professional Experience Practice Analysis Essay (PEPAE)

Assessment Outline: The Nursing Process is a sequence of problem-solving steps used to identify and manage the health problems of patients. This assessment requires you to use the Nursing Process as a framework to discuss the nursing management of a patient that you have cared for while on PEP. Some elements (supervised head-to-toe assessment and identification of priority problems) will be completed during your PEP experience, whilst writing up and presenting your patient assessment is to be completed both during and after your PEP experience.

Step One- whilst on PEP
In collaboration with your Clinical Nurse Educator (CNE) or Clinical Preceptor, students are to identify an appropriate patient to perform a full and comprehensive systematic physical and psycho-social nursing assessment. Please ensure that you use the head-to-toe assessment guide (appendix E) when performing your assessment. Your Clinical Nurse Educator/preceptor is to witness the head-to-toe assessment and sign off the paperwork set out in appendix E, which will then be submitted as an appendix as part of your PEPAE submission. The psych-social assessment does not need to be witnessed but is essential to complete with your patient. It includes past medical history, family history, current medications, social history, living arrangements and carer responsibilities.

Next, having completed the patient assessment, you are to sit with your CNE/preceptor and identify all priority problems for your patient and document these on appendix F. This is to be submitted as an appendix as part of your PEPAE submission. Please note that these appendices do not count towards your overall word count for this assessment.

Step Two - writing up your head-to-toe assessment:
The final part of this assessment requires you to write up the results of the head-to-toe assessment and develop a plan of care to address the needs of the patient. You are to provide an overall introduction to the essay, an introduction to the patient and a written summary of the head-to-toe assessment, and a conclusion
Introduction to the patient:
Medical diagnosis
Past medical and surgical history
Social history
Relevant family medical history
Allergies and adverse reactions to medications

If your patient has a very long list of medications, you can present the complete list as an appendix, but please refer to any specific medications linked to the patient and their presentation in this section
Summary of clinical course whilst in hospital

Summary of head-to-toe Assessment:
Discuss the objective (signs) and subjective (symptoms) data collated from the nursing assessment of the patient
This account is to utilise a head-to-toe system analysis/framework
Normal and abnormal assessment data is to be outlined

Then, using the template presented in appendix G, identify two (2) priority problems (1 actual and 1 potential), along with their associated NANDA nursing diagnosis statement, SMART goals, evidence-based intervention and rationale, and an evidence- based outcome statement for each priority problem/NANDA diagnosis (see below for the breakdown of requirements).

Diagnosis:
Identify one (1) actual and one (1) potential healthcare problem that the nurse is accountable and responsible to treat. The problems identified in this discussion are to directly link to the patient's abnormal assessment findings outlined in the assessment data. Actual and/or potential healthcare problem MUST be written using NANDA taxonomy.

Planning:
Patient goals are directly related to the patient's problem as stated in the nursing diagnosis. In clinical practice, nurses
establish patient goals utilising a SMART (specific, measurable, achievable, realistic and timely) approach.
Provide a description of the expected benefit &/or intended outcomes within a timeframe and the plan of care that is to be implemented by the nurse, this needs to be supported by literature
One (1) SMART goal is to be outline for each nursing diagnosis.

Implementation:
A nursing intervention is defined as any treatment based on clinical judgement and knowledge that a nurse performs to enhance a patient's health care status.
A description of one (1) independent nursing intervention and one (1) collaborative intervention to address the patient's actual problem, and one (1) independent nursing intervention to avert the patient's potential problem is to be discussed and supported by literature.
The nursing interventions discussed are to be within the scope of practice of a first year second semester entry-to-practice nursing student
Evidenced-based rationales with reference to the current literature are to be provided for each nursing intervention

Expected Outcomes:

For this to be successful please write your RUMBA statement (what you predict will occur because of your intervention, no more than one sentence). When writing outcomes, the nurse should ensure that the outcome statement is written in measurable behavioral terms. A useful mnemonic here is RUMBA i.e. the outcome statement should be realistic, unambiguous, measurable, behavioral, and achievable. The outcome statement should be written sequentially, and with timeframes.

Outcomes of nursing and collaborative interventions

In clinical practice, nurses evaluate the appropriateness of their nursing interventions, i.e. whether the patient's nursing care goals have been met.

Here discuss the outcome of your chosen interventions and determine if what you set out to achieve in your RUMBA statement was successful. If not, why not? On reflection how did your chosen nursing interventions impact on the outcome?

conclusion

Attachment:- Professional Experience Practice Analysis.rar