Nursing care of a person with altered neurological system

Nursing care of a person with altered neurological system
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Please complete the assessment task on the next page.
Assessment 1: Topic

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Nursing care of a person with altered neurological system
This is Gavin
You will be caring for him today.
Shift handover:
Gavin, a 24year old male, was admitted to your ward from the emergency department during your afternoon shift for observations and further investigations of his neurological symptoms.
Gavin was celebrating Australia Day with mates at Florence Falls. After a day of drinking alcohol, he jumped into the waterfall from an unknown height and hit his head on rocks. Friends stated he was dragged from the water immediately and that there was a brief loss of
consciousness and he has numerous cuts and abrasions. His friends confirm Gavin drinks a case of heavy beer most days after work and binges on the weekends.
Gavin was brought in by ambulance to the emergency department with spinal precautions in place due to mechanism of injury. He has an altered Glasgow Coma Scale with altered sensation in his lower extremities. He also had multiple cuts and abrasions and excessive sunburn to his face, chest and back.
In the emergency department Gavin has had a CT scan of his head and spine which has not detected anything abnormal. However, due to his level of intoxication, confusion and sensation deficit to lower extremities, he is to be admitted to the medical ward for further investigations and observations.
Prior to transfer his observations have been charted and remain stable;

GCS14 (E4, V4, M6) PERL 4+ R/L BP 130/70 SaO2 99% on 2L O2 via nasal prongs
Temp 36.6OC BGL 5mmol/l HR 98 regular Neurovascular observations are
C=normal, W= warm, M=active, S=partial
AWS 5 Pain score 5/10 RR 14 Generalised pain to head and torso

*PERL = pupils equal reactive to light
Medical orders
• hourly neurological and neurovascular observations
• spinal precautions to remain in place
• nil by mouth with fluid balance
• Alcohol Withdrawal Scale observations with prescribed pharmacological treatment
Medications orders
• intravenous maintenance fluids – Normal Saline (0.9% sodium chloride) 1000mls over
12 hours
• Antiemetic – IMI metoclopramide prn
• Analgesia – oral paracetamol 4/24 and S/C morphine prn
• Benzodiazepine – oral Diazepam prn as per the AWS scale regime
Assessment 1 Tasks:
Using the template provided in the Assessment 1 folder and, based on the handover you received at the beginning of your shift today, other information included below and current reliable evidence for practice, aIDress the following 6 tasks.

Do not make up or assume information in relation to or about Gavin. Only use what you know from the information you received today.

Note: Students are expected to demonstrate they have read beyond the set texts to prepare their nursing care plan. Reliance on text books alone is no guarantee that your information is current and reliable evidence for practice. However, set texts are a good place to start to identify key points and to develop search strategies to locate appropriate journal articles.

Task 1:

Based on the handover information and in grammatically correct sentences identify;
• Your three (3) nursing priorities to ensure you are prepared to received, admit and provide immediate care to Gavin on admission.

For each priority above, identify
• What it is related to?
• Why it is a priority for you today?
(200 words, 5 marks)

Task 2:

Based solely on the handover you have received and using the template provided, develop a full nursing care plan for Gavin. Your plan must aIDress the physical, functional and psychosocial aspects of care.

For each nursing problem on your plan, identify your
• Goal of care
• Interventions
• Rationales for interventions
• Expected outcome of care

Notes for Task 2 only
• Dot points may be used in care plan template
• Appropriate professional language must be used, no abbreviations or nursing jargon
• Rationales must be appropriately referenced. It is strongly recommended only current, reliable journal articles be used as references when providing rationales
(750-­-1000 words, 30 marks)

Task 3:

Two important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications and how to monitor the patient to ensure they are responding to the prescribed medications as they should.

• In grammatically correct sentences briefly explain why Gavin has been prescribed
o Paracetamol orally o Diazepam o Normal Saline (0.9% Sodium Chloride) AND
• Explain o The nursing responsibilities associated with administering the three (3) medications/fluid above
o How you will assess or monitor Gavin to ensure he is responding appropriately to these three (3) medications/fluid you are administering today?
(350 words, 10 marks)

Task 4:

Patient has deteriorated and needs transferring

Using ISBAR and incorporating the aIDitional information below prepare a written handover for the nurse taking over Gavin’s care in ICU. Handover must aIDress the physical, functional and psychosocial aspects of care and reflect any changes required to your nursing care plan above. You must use appropriate professional language with no jargon or abbreviations.

During your shift you notice the following observations

GCS12 (E3 V3 M6) Pupils unequal R5 L3 sluggish BP 154/65 HR 62 regular
Weakness to L leg SaO2 97% Hudson Mask 6Lt Temp 37.3 Decreased urine output
Decreased level of consciousness AWS no changes RRR 26 Unable to assess pain

• Gavin stated he had increased headache pain with projectile vomit when log
rolling for pressure area cares earlier in the day
• Urine osmolality pathology has been sent
• No arterial blood gases done
• The cannula in his right arm has signs of inflammation yet is still flushing well.
• An urgent CT scan was been attended which showed signs of bleeding with increased intracranial pressure.
• Gavin is for urgent transfer to ICU
(250-­-300 words, 5 marks)

Task 5:
An important part of the clinical reasoning process is to reflect on what you have done and learnt and to identify areas where you need further development and/or learning.

• Reflecting on the nursing care plan for Gavin identify three (3) things you have learnt from completing this assignment that you can take into clinical practice.
• Include in your answer why you think those three (3) things are important to quality nursing care.

(200 words, 5 marks)
Notes for Task 5 only

Reflective writing is the opportunity for you to document your thoughts and feelings. This requires a different writing style to the rest of the assignment.

As you are expressing your thoughts and feelings, you write in the first person. It is expected to see words like “I” and “my“ and phrases like “I have learnt…”, “I now understand or realise that…”

It is not appropriate to reference your own personal thoughts and feeling. However, if you refer to professional nursing standards and codes, information from specific sources (eg a text book or NUR251 Learnline) or draw on your understanding of the role and scope of practice of the registered nurse, you must provide a reference to support your statements.

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