Medical Surgical Nursing-Report Writing Assignment Topic: Nursing care of a person with a… 

NUR250: Medical Surgical Nursing-Report Writing Assignment

Topic: Nursing care of a person with a major burn

Shift handover:

Marion was admitted 5 days ago with burn injuries to her lower legs, back and posterior side of her lower arms. Extent of the burns is estimated at approximately 40% and depth is variable but there is an extensive area of partial and full thickness burn on her back and posterior thighs.Marion was transferred to the ward from the intensive care unit yesterday afternoon following fluid resuscitation and initial surgical debridement. She is now 6 days post burn injury. Today she is booked on the afternoon theatre list for further debridement, harvesting of autologous split skin grafts and replacement of the nasogastric tube. Overnight her vital signs have been stable, urine output satisfactory and she is reporting she is comfortable with minimal pain. She is currently nil by mouth in preparation for theatre
but has been tolerating oral food and fluids prior to this. However, there has been some concern about caloric and nutrient intake. She has intravenous fluids running at maintenance and an indwelling catheter in situ. She is not reporting any nausea or other discomfort at present but is getting frustrated at having to rely on others to help with her personal care and daily activities.Full and partial thickness burns are covered with a silver impregnated dressings that are difficult to keep in place due to location of injuries. Superficial burns have hydrogel dressings where possible and some areas require regular application of an emollient. Current medications include a transdermal fentanyl patch, panadeine forte 4/24 and nitrous oxide prn as well as an anti-emetic, vitamin and mineral supplements and an aperient.
Prophylactic intravenous antibiotics were commenced this morning.Her husband is visiting regularly but his time is limited due to childcare and work commitments. He brings their 2 young children on most afternoons for a short visit. There are no other family members living locally but her mother and sister are arriving in the next few days. Marion is quite concerned about how the family is going to manage over the next few months.

Question:

Task 1:Based solely on the handover you have received and in grammatically correct sentences identify the:
1. 3 nursing problems you think are the most important while caring for Marion today AND For each nursing problem above, identify
a.What it is related to
b. Why it is a priority for you today

Task 2:Based solely on the handover you have received and using the template,develop a full nursing care plan for Marion today. Your plan must address the physical,functional and psychosocial aspects of care.For each nursing problem on your plan, identify your
a. Goal of care
b. Nursing interventions or actions
c. Rationales for interventions
d. Expected outcome of care

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 prescribed medications as they should.In grammatically correct sentences and using current, reliable evidence for practice, briefly explain why Marion has been prescribed

a. Fentanyl via transdermal patch
b. Vitamin and minerals supplements
c. An aperient ANDExplain
d. The nursing responsibilities associated with administering the 3 medications above
e. How you will monitor Marion to ensure she is responding appropriately to these 3 medications you are administering today

Task 4:An important and legal requirement of nursing practice is to communicate relevant information,
actions and outcomes related to patient care and provide accurate reflection of the health status of the patient, their responses to care and the patient’s perspective.Using a succinct, narrative format and only the relevant information in the shift handover and the additional information below
a. Write a progress note entry that clearly and succinctly outlines the important information other health professionals, including other nurses, need to know about Marion at the end of your shift today Additional information you need to know for Task 4 During your shift the following information and events have occurred On return to ward following surgery
b. Post op orders: NBM, nasal prong oxygen to continue til review tomorrow morning, IV fluids, IDC, analgesia changed to morphine via PCA, IV antibiotics continue, burn dressings to remain intact for 24 hrs, donor site dressings to remain intact for 3 days, NBM until review, no enteral feeds until review.
c. Post op assessments:
d.Vital signs slightly elevated
e. 02 saturations 98%
f. Pain score 3-4
g. Drowsy but easily roused
h. Dressings intact, small amount of ooze
i. IV site satisfactory
j. Urine output > 30 ml/hour

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.In this item, reflect on your experience in preparing this assignment and identify,The three (3) most important things you have learnt about your level of underpinning knowledge and understanding and/or clinical reasoning skills while completing this assignment.Why these three (3) things are most important for you