Healthcare terminologies and abbreviations.
How would you discuss the nursing interventions you have identified in the case scenario and what evidence have you used to support your clinical decisions and actions? Refer to your FILA and SOAP notes + evidence from the literature.
clinical decision making and reasoning 4 pages reflective writing 1 page
This written assessment piece is based on the following clinical scenario.
Case: Mr Larry Lyons
Mr Larry Lyons is admitted to the East Wing surgical ward of University Hospital and scheduled for a cholecystectomy. It is intended that the procedure will be performed by laparoscopy, however a laparotomy may be required. As part of his perioperative care you are required to plan his nursing intervention for perioperative care (see Skill 36-1 in your Dempsey text).
On admission you documented his vital signs as follows:
Vital signs: T 376C, P 106, RR 22, BP 140/94, SpO2 97%, Wt 60 kg, Ht 198cm
UA: + protein, + blood, ++ nitrites, pH 5
Pain score: 6/10
Mr Lyons states to you that although he is willing to have an operation that may involve additional procedures, that is the laparotomy, he is unwilling and fundamentally opposed to providing consent for a blood transfusion.
Part 1: Documentations
1.Glosssary of terms – define a minimum of 12 healthcare terminologies and abbreviations pertaining to this case and those used in your documentations.
2.Case analysis: Using the FILA framework, analyse the clinical situation and plan your nursing intervention (2 – 4 pages).
3.Nursing documentation: Using the SOAP Framework, prepare your documentation for Mr Lyon’s care.
4.Handover: Using the SBAR Framework, prepare your handover nursing notes.
Part 2: Essay
Clinical decision making and reasoning: This is a written assignment in essay format (1000-1200 words). Based on your analysis and documentations, (refer to your completed FILA, nursing documentation and handover notes) and using evidence in the literature, explain your clinical decisions and responses to the case scenario. Use the following points to guide your essay writing:
1.How would you introduce the case scenario and your assessment of Mr Lyons?
2.How would you discuss the nursing interventions you have identified in the case scenario and what evidence have you used to support your clinical decisions and actions? Refer to your FILA and SOAP notes + evidence from the literature.
3.How have you applied person-centred care to the case scenario and what framework have you utilised? Refer to your FILA, SOAP and SBAR documentations + evidence from the literature.
4.What is your position regarding Mr Lyons’ disclosure of his issues of informed consent (see Chapter 11 in your Dempsey text) around blood transfusion? Refer to your FILA, SOAP and SBAR documentation + evidence from the literature.
5.How would you summarise your clinical findings and do you have any recommendations?
Part 3: Reflective written piece concerning your professional learning and development as a nurse
Professional growth through learning: Throughout the semester, we have placed great emphasis on person-centred care, professionalism and ethical practice as core to the practice of a responsible nurse. Ensure that you have a good understanding of these concepts when responding to Part 3 Assessment task 3.
•Prepare a one (1) page summary of your learning journey of responsible nursing practice, focusing on the key concepts: person-centred care, professionalism and ethical practice. As this is a reflective writing piece, use the first person approach, i.e. use of pronouns such as “I” or “me” is expected.
Parts 1 & 2 of Assessment task 3 form part of your written assignment in essay format. Your written assignment must adhere to academic writing conventions, i.e. you need to present arguments and opinions, and use evidence from the literature to support your position, using appropriate referencing conventions. Use the A3 Marking Criteria when preparing your essay.