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, address the following tasks. Do not make up or assume information in relation to or about Ruby. Only use what you know from the information you received today.
Based on the case scenario and in grammatically correct sentences identify:
- Four (4) priority nursing assessments you would conduct prior to transferring Ruby to the ward?
For each assessment you have identified explain:
- Why it is necessary for Ruby’s condition and nursing care?
- What consequences can occur if this assessment is not completed accurately?
- What chart or document you would use to assist with your assessments?
Task 3: Patient education
An important aspect of nursing practice is to effectively and succinctly communicate relevant information related to ongoing disease management or prevention of reinfection or deterioration on discharge. Patient education and discharge planning starts on admission and you need to provide Ruby with education during your shift in preparation for discharge home.
- Explain three (3) important points/topics you will need to include in Ruby’s preparation for discharge to aid healing and prevent further illness. For each education point identified provide:
- One (1) strategy to assist Ruby to implement the education into her daily routine.
Task 4: Documentation
An important legal requirement of nursing practice is to effectively and succinctly document relevant information, actions and outcomes related to patient care and provide an accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.
- Make an entry into Ruby’s patient progress notes documenting the successful implementation of your nursing care plan. You can choose any progress note format but your documentation must:
Ø Demonstrate person-centred care
Ø Adhere to the legal and professional standards for documentation
Ø Appropriate professional language must be used – legally recognised abbreviations may be used in this task (handover) but a KEY with full terminology must be provided after the assignment references – key will be excluded from word count tally.