Nursing assessment and care of the Patient with Pneuomina

You are working as a student nurse in a metropolitan hospital. Steven Smith is a 32 year old man admitted to the medical ward with bacterial pneumonia. Steven appears to be asleep on his side when you enter the room and his face seems pale. You can?t see the rest of him as the bedclothes are pulled up to his neck. You can however see his chest rising and falling under the bedclothes. You check the documentation and his vital signs 2 hours ago were BP 135/80mmHg and pulse 96b/min. His respiratory rate is recorded as 28 respirations/min and the comments column on the observation chart reads: moderate recession/working hard, decreased air entry in both lung bases, scattered coarse crackles and wheezes upon auscultation and oxygen saturations 92% in room air. The sputum cup next to his bed contains yellowy-green sputum. His temperature is recorded as 38.1oC He has intravenous (IV) therapy ordered & running N/Saline 0.9% 1000ml/12 hours and is ordered IV antibiotics. Other information in the chart gives the following details: 2 week history of „flu? like illness with productive cough, presented to hospital following GP referral for chest X-ray, experiencing intermittent chest pain worsened by coughing and deep breathing, smoker 30/day, works in the building & construction industry as a labourer and divorced 5 years ago. After Steven finishes his rest, you need to perform certain nursing-based interventions to aid his recovery.
The 1800- word essay should cover the points below:
• Introduction (100 words): State an overview of the patient’s condition and identify TWO priority nursing problems. Give a brief plan for the essay topics.
• For the first problem (800 words): Briefly explain how it relates to the patient’s assessment data. Identify TWO priority nursing interventions to address the problem. Discuss briefly the nursing interventions you will implement (explain what is involved in implementing the intervention, why it is suitable, any relevant positive or negative aspects/considerations) and support/justify the use of these interventions with reference to current evidence-based literature. Outline the evaluation criteria/data that would indicate that each intervention is improving or resolving the identified problem.
• For the second problem (800 words): Briefly explain how it relates to the patient’s assessment data. Identify TWO priority nursing interventions to address the problem. Discuss briefly the nursing interventions you will implement (explain what is involved in implementing the intervention, why it is suitable, any relevant positive or negative aspects/considerations) and support/justify the use of these interventions with reference to current evidence-based literature. Outline the evaluation criteria/data that would indicate that each intervention is improving or resolving the identified problem.
• Conclusion (100 words): Briefly restate the patient’s condition and problems and how the nursing interventions can benefit the patient’s health.

Refer to current academic peer-reviewed journal articles to justify your ideas.
Format of Assessment 2
• A fully completed with CORRECT information and signed assignment cover sheet must be attached.
• All questions should be attempted and written in essay format
• Margins: 2cm on 4 sides; & line spacing: at least 1.5; Font size: 12
• Adherence to the stated word limit is required
• QUT APA referencing style
• A full reference list is required at the end of the assignment. For further information on referencing at QUT, refer to QUT Cite/Write via http://www.citewrite.qut.edu.au
• It is expected that students will familiarise themselves with the required essay format as outlined in the academic writing advice located at http://www.issupport.qut.edu.au/language/advice/academic.jsp This provides valuable information to assist you to write a high quality academic paper.

Additional notes
Please pick the two priority problems, (assessment data that supports the problems – a simple pathophysiology explanation and how it relates back to the problem.) (This will need to be referenced.)
Clearly state what the two interventions each for both problems. (4 in total)
Believe these to be the priority problems and interventions.
Priority problem 1- Chest pain preventing effective deep breathing, coughing and effective airway clearance.
Intervention 1 – Administer analgesia – nurse initiated analgesia (paracetamol) (referenced) ( basic, pathophysiology why it works)(referened).
Intervention 2- Nurse initiated Humidified saline nebs. (referenced) basic, pathophysiology why it works)(referenced).
Priority problem 2 – Oxygen saturations are 92% on Room air.
Intervention 1 –Apply 0² Therapy – 2 litres of oxygen via nasal prongs. (referenced) ( basic, pathophysiology why it works) (Referenced).
Intervention 2 – positional – eg semi fowler (referenced) ( basic, pathophysiology why it works) (referenced).
All related back to the scenario

Using current peered reviewed journal articles that are evidenced based and no older than 2007 to fulfil the following questions.
1. What is the current evidence saying what is the best practice in this intervention?
2. How is it intervention implemented?
3.What is the outcomes wanting to be achieved from this intervention?. ie how it address the problem/priority.
References from databases such as Cinahl, Joanna Briggs Institue, Crochrane, Nanda. Can also use. Queensland Health Hospital Policy, procedures and guidelines. Relevant to Nursing Queensland.
Keeping all resources relevant and link it to the scenario.
Matching the case scenario assessment data to priority problem. (only write about the existing data that is supplied.)

Please forward any questions for clarity

Criteria-referenced Assessment (CRA): Assessment 2 Student Name: Student Number:
Clinical Knowledge, Skills & Decision Making
Pass Fail
7 6 5 4 3 2 1
Demonstrates an understanding and application of nursing assessment and prioritisation of problems In your case study you have:
• provided a comprehensive explanation of all the significant signs/symptoms which link to the identified priority problems
• analysed comprehensively patient assessment data and applied clinical knowledge to synthesize/identify correctly 2 priority problems
• applied clinical knowledge to synthesize comprehensive evaluation criteria to measure the success of all priority nursing interventions In your case study you have:
• provided a comprehensive explanation of nearly all of the significant signs/symptoms which link to the identified priority problems
• analysed patient assessment data and applied clinical knowledge to synthesize/identify correctly 2 priority problems
• applied clinical knowledge to synthesize/ identify appropriate evaluation criteria to measure the success of all priority nursing interventions
one significant concept in was missing and/or not described in sufficient detail
In your case study you have:
• provided a detailed explanation of some of the significant signs/symptoms which link to the identified priority problems
• analysed most patient assessment data and applied some clinical knowledge to synthesize/identify correctly 2 priority problems but
• applied clinical knowledge to synthesize/identifiy evaluation criteria to measure the success of all priority nursing interventions, but
some significant concepts were missing and/or not described in sufficient detail
some significant evaluation data missing and/or not described in sufficient detail

In your case study you have:
• provided an explanation of some of the significant signs/symptoms which link to the identified priority problems
• analysed some patient assessment data and applied some clinical knowledge to synthesize/identify correctly 2 priority problems but
• applied some clinical knowledge to synthesize/identify evaluation criteria to measure the success of all/two priority nursing intervention(s), with superficial and/or incorrect detail
quite a few concepts were missing and/or not described in sufficient detail In your case study you have:
• attempted to provide an explanation of significant signs/ symptoms and to analyse patient data to identify 2 priority problems, but:
there was little/no coverage of the essential pathophysiological concepts linking your identified problems to the patient data in your explanation, and/or
one or more of the priority problems were incorrectly identified
evaluation data was inadequate/inappropriate/not present

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