NURS 1002 Assessment 1: Case Study Report Guidelines

PATIENT NAME: Jenny Banks
DOB: 03/11/1966 52 Years Female
PRINCIPAL DIAGNOSIS: Acute pneumonia
Summary of Events
Jenny is a 52-year-old woman who has had a cough and has felt generally unwell for 2 weeks. She has been feeling feverish and exhausted the last few days. Jenny smokes, reporting she smokes approximately one pack per day and has done so for the past 30 years. She states she normally has an intermittent cough, sometimes productive of clear sputum.
She saw her general practitioner (GP) as she stated she felt much worse and was feeling quite breathless. Her cough had become productive of a green-coloured sputum.
The GP found that Jenny was lethargic but oriented, and auscultated coarse crackles in the right lower lobe (RLL) of her lung. She was coughing up green sputum and her doctor took a specimen for culturing.
Her vital signs were:
• BP – 135/85 mmHg
• PR – 104 beats/minute
• RR – 28 breaths/minute
• T – 38.9°C
• SpO2 – 92% with no supplemental oxygen
The GP gave Jenny a prescription for oral antibiotics. He sent her for a chest X-ray as he is suspecting bacterial pneumonia.
Jenny has a past history of hypertension, hypercholesterolaemia, and obesity.
Her current medications are:
Atorvastatin PO Atenolol PO Spiriva inhaler
Salbutamol inhaler as required
Social:
Mrs Banks lives with her husband and does part time shiftwork as a cashier at the local RSL club. She enjoys her craft classes once a week and has a good social network of friends centering around her involvement in the club. Jenny has two adult children who live interstate.
Investigations by GP
The results of Jenny’s further investigations confirm the presence of RLL pneumonia. The chest X-ray shows extensive infiltration of the infection throughout the RLL. When Jenny presents back to the GP, she is noticeably more lethargic and feverish, and she states her cough has been getting much worse
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over the past 3 days and she is not sleeping well.
Her current vital signs are:
• BP – 140/82 mmHg
• PR – 105 beats/minute
• RR – 30 breaths/minute, with very shallow breaths
• T – 39.2°C
• SpO2 – 90% with no supplemental oxygen
The GP arranges for Jenny to be admitted to hospital as her condition is deteriorating.
Presentation to the Emergency department:
1. Increasing SOB with Flu- like symptoms (2/52)
2. Current smoker +++
3. Hypertension
4. Hypercholesterolaemia
5. Obesity
Patient Complaints: Severe shortness of breath (SOB) with a productive cough and lethargy Past medical history (PMH) :, Hypertension, hypercholesterolaemia, obesity
Meds: Atorvastatin PO, Atenolol PO, Spiriva inhaler, Salbutamol inhaler as required Antibiotics (2/52) (Taken over the last 2weeks)
O/E A – Patient talking in half sentences
B – RR Tachypnoea 30, Dyspnoeic, SOB
Short shallow breaths, use of accessory muscles when breathing. Productive cough with yellow/green sputum
↓AE bases with bibasal creps/crackles, no wheezes. Percussion: Dull over bases
SpO2 92% on 2L O2
Spirometry consistent with emphysema
FEV1
=
1.02
=
59%
FVC
=
1.49
=
71%
C – HR 106 regular, BP 145/80, warm, patient dry despite ↑JVP due to pulmonary hypertension,
ECHO Normal LVF, no valvular disease, enlarged RA
D – alert, GCS 15, PERL 3+
Abdomen soft, non-tender, no organomegaly detected, Calves soft
E – Temp 39.0
F – RR 30, BP 140/80, PR 106, GCS 15, Diaphoretic
G- BGL 4.1mmols/L
I – Chest X-ray – AP erect. There are areas of congestion in the bases. There is patchy consolidation at the right lung base with loss of costal-phrenic angle on (R) side.
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ABG-Respiratory alkalosis with possible respiratory compensation, likely driving Tachypnoea
pH
7.48
PaCO2
28
PaO2
64
Bic
19
BE
Bloods – ↑ LFTs
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Glossary of terms and abbreviations
AE Air Entry
BP Blood pressure BGL Blood Glucose level
ET End Tidal CO2 is the amount of CO2 in exhaled gas FEV1 Forced Expiratory Volume in 1 second
FVC Forced Vital Capacity GCS Glasgow comma
LFT Liver Function Test
JVP Jugular Venous Pressure LVF Left Ventricular Function LOS Loss of consciousness O/E On Examination
PO Per oral
RA Right Atrium
RR Respiratory rate
RLL Right Lower Lobe
PERL Pupils equal and reacting to light PMH Past or previous medical history PR Pulse Rate
SOB Short of breath
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SpO2 Saturation of oxygen onto haemoglobin in arterial blood
(L) Left
(R) Right
Reference
Crisp, J., Douglas, C., Rebeiro, G., Waters, D. (2017) Potter and Perry’s Fundamentals of Nursing, (5th ed.). Sydney: Elsevier, Chapters 5, 24, 25, 37.
Photo https://goo.gl/images/5Wdda8
Case study report
This assessment will require you to apply the Framework of Practice Thinking, to clinical data related to this specific health condition – pneumonia. You will be particularly exploring the questions of “what’s going on here?” and “What does this mean?”
Details of the case study for this assessment will be provided during the tutorial session in week 5. In preparation for completing this assignment, it would be advisable to become familiar with the framework of practice thinking and the physiology of pneumonia. Leading on from your tutorials and labs you will be introduced to a pneumonia case study. This will be used as a guide for your case study report. You are required to write a 2000-word report. In the report, you will be required to examine the clinical data for the case and interpret the data in relation to the physiological changes occurring in the patient. You are also required to support your responses with evidence from the nursing literature.
In addition to your case study report, you are required to submit a 250-word reflection on your understanding of the University’s policy on Academic Honesty and how you have met the policy requirements in this assignment. This is a compulsory component is a requirement of the assessment. That is, you must complete this component in order to meet the requirements of the assessment, but it will not contribute to the academic value (grade) for the assessment.
Format: Written report
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Length: 2000 words maximum
Due: Monday 6th May (week 10) 2019 before 0900
Weight: 50%
Students should note that this assessment will be submitted to similarity detecting software. SDS programmes provide the subject co-ordinator with an estimation of the extent of similarity between the students work and a broad range of academic literature. This estimate of similarity is brought to the attention of academic staff who will be required to undertake a comprehensive assessment of plagiarism prior to any action being taken.
A detailed marking rubric for this assessment is available on the Canvas site in the assessment section.
Guidelines for the Case study report
This report requires you to apply theory and concepts to the case study provided. You will need to combine the theoretical approach of an essay with the practical nature of a report. This report should contain factual, current, well referenced information from the texts and literature.
Presentation
This report should combine descriptive and explanatory writing using the subheadings given below and supported by the literature. Tables and graphics may be included (but must be referenced) and are not counted in the word count.
Ensure each page is numbered and includes a header and/or footer. Use consistent formatting and appropriate academic and medical language. Writing should be clear and succinct. Please make sure you edit, and proof read your work to avoid lost marks from spelling and grammatical errors or poor presentation. Make sure the font size and style is easily read. It is recommended that you use Arial font, with the minimum font size 10 point. Stay within the word count to prevent penalties. The word count should include all words in the body of the case study. Do not count the reference list or tables.
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Referencing
For this case study report 8-10 references are adequate. You can include relevant readings from the unit of study core readings. Ensure resources are acknowledged appropriately and systematically using APA 6th referencing
Structure and organisation
– Formatting and structure as per a case study report
– Correct use of abbreviations
– In alphabetical order on a new page
– Sticks to word count
– Page numbers
The structure of report writing means headings are allowed. This report is divided into four parts. Make sure each part of the report is clearly identified and meets the specific requirements of the assessment.
Use the following subheadings to structure your case study report:
Part 1. Introduction to the patient and the use of the framework of practice thinking (approx. 250 words)
Under this heading you should introduce the patient and provide holistic overview of the patient. This will include the patient’s situation and history drawing links to the patient’s social and past history. You should also introduce the framework of practice thinking and discuss how you will apply the first two parts of framework of practice thinking (what is going on here and what does this mean?) in this report.
Part 2. Altered physiology and associated symptoms related to principal diagnosis (approx. 750 words)
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Under this heading you provide a definition and description of the principal diagnosis of the case study. Discuss the altered physiology and associated symptoms as a result of the disease process. That is, how the disease impacts on normal physiology and the symptoms it causes, for example, how does the disease impact on the patient’s respiratory status and lifestyle.
Part 3. Health Assessment (approx. 750 words)
Under this heading you discuss your interpretations of the data presented in the case study. Use the SOA of the SOAPIE format (see below) and the A-G assessment tool to document your findings. In your interpretation you are required to analyse the data and link the patient’s assessment findings to the altered physiology related to the diagnosis. To support your findings, always use relevant nursing literature and evidence.
S Subjective data O Objective data A Assessment data
Students may use tables to summarise their assessments and data interpretation such as the table below. Use relevant literature to support your findings and ensure it is referenced.
Data
Subjective
Objective
A-G Assessment
Data analysed and linked to the assessment findings
Remember: In this case study report, you are NOT required to describe your nursing care response (for eg for dyspnoea position the patient, provide oxygen and medication) based upon your assessment of this clinical situation.
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Part 4. Conclusion (approx. 250 words)
A short conclusion to summarise the key points covered in the case study
Part 5. Academic Honesty Policy (approx. 250 words but not counted in the overall word count)
Under this heading you are to write how you have met the University’s Academic Honesty in Coursework Policy 2015 requirements for this assignment. You are required to submit a 250 word reflection on your understanding of the University’s policy on Academic Honesty and how you have met the policy requirements in this assignment. This component is a compulsory requirement of the assessment, that is, you must complete this component in order to meet the requirements of the assessment, but it will not contribute to the academic value (grade) for the assessment.
NURS1002 Marking Rubric for Assessment 1: Case study report
Content: 35%
Fail
Pass
Credit
Distinction
High Distinction
• accurately applies clinical terms and concepts from the unit of study
Content is somewhat
Content is mostly relevant to the case
Content is relevant and
As for credit plus- Contains
As for distinction plus-
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• provides a definition and description of the principal diagnosis
• addresses key aspects of the altered physiology and its impact on normal physiology
relevant to the case study. Shows
No or little resemblance to address the assessment guidelines. No evidence or insufficient evidence of further reading and understanding of the altered health issue. And it’s impact.
study. Demonstrates some attempt to meet assessment guidelines. Demonstrates some evidence of further reading and some understanding of the altered health issue and its impact.
adequately meets assessment guidelines. Demonstrates understanding of the altered health issue and its complexities in this case study.
evidence of broad reading from a range of sources. Demonstrates sound understanding of relevant issues and critical areas in the health issues and its complexities.
demonstrates initiative in research and evidence of extensive reading. Shows a complex understanding of the altered health issue and its complexities.
Structure and organisation : 15%
• overall structure suits the report presented
• the introduction introduces the patient with a holistic overview linking past and social history
• conclusion summarises key points
• body paragraphs are under relevant headings and structured to continue the flow of the report
Does not met basic requirements; No or poor introduction omitting key issues and relevant/holistic information.
Incorrect sentence structure and
Inappropriate use of headings. Ideas not
Meets some basic requirements Satisfactory introduction but lacks clarity.
Most key issues identified with a basic over view linking some aspects of patient history. Structure of the report is adequate and satisfactorily organised.
Addresses requirements introduction evident but requires further development. Report is clearly written with a holistic view. Evidence of trying to link relevant patient history. Logically organised.
As for credit plus- introduction is written from a holistic view and clearly introduces the key issues. Evidence of a deep understanding of the topic. Effectively links relevant patient history using a
As for distinction plus Very effectively introduces the reader to the patient and associated health issues from a holistic point of view .clear interpretation of the content linking relevant history –
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logically organised. No/vague conclusion.
Sentence/paragraph structure requires some development structure
Conclusion is evident however key points not always clearly summarised and/or new information is evident.
Correct sentence and paragraph, use of language and specialised vocabulary Conclusion summarises content no new information. Structure requires further development
well-developed language and vocabulary. Successfully summarises the content.
Application and synthesis 30%
• applies the S,O and A of SOAPIE data relative to the case study
• comprehensively employs a systematic assessment approach to interpret and analyse the clinical data presented in the case study
• application and synthesis of the data is supported by relevant scholarly sources including the suggested readings.

Inappropriate application to the case study. Vague and unstructured assessment approach
Poor use of subjective and objective data collection and synthesis. No or limited evidence of examining and interpreting the clinical assessment data for the
Limited application to the case study. Demonstrates a basic understanding of subjective and objective data collection and synthesis. Some evidence of examining and interpreting the clinical assessment data for the case in relation to the physiological changes occurring in the patient.
Adequate application to the case study Demonstrates a good understanding of synthesis, analysis and linking of clinical assessment data from a range of credible sources.
Evidence of a deep understanding of synthesis, analysis and linking of assessment data from a range of credible sources.
Strong evidence of advanced synthesis, analysis and linking of assessment data from a broad range of credible sources
Displays an advanced application of relevant critical thinking skills.
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case in relation to the physiological changes occurring in the patient.
Referencing and Academic writing style : 15%
• Academic writing style and referencing well structured, logically sequenced and grammatically correct.
• Follows APA 6 referencing style.
• Adheres to word limit
Unclear and difficult to follow. Minimal linking of sentences. The errors detract significantly, but the meaning is discernible with some effort. Many inaccuracies with the APA 6 referencing style. Not all references are cited. Uses of commercial references. Insufficient credible references
Easy to comprehend. No variation of the in-text citation format. The writing is somewhat organised and sentences somewhat link to one another. Minor typographical errors with referencing. Lack of in text citation and minimal nursing references to support work.
Well-developed written communication. The writing is mostly organised and the sentences mostly link to one another. Some minor errors with grammar. Credible and relevant referencing style on most occasions.
Well-developed written communication. Accurate referencing style on most occasions. Credible and relevant use of nursing references. Carefully edited.
Very well crafted. Demonstrates high level scholarship. Carefully edited. Accurate referencing style on all occasions. Excellent use or resources and nursing references.
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Work appears not edited. Or proof read.