NURSING CASE STUDY ASSESSMENT TASK

Unit Code: NURS4023

Unit Title: Chronic Illness and Palliative Care Nursing

Assessment Type: Comprehensive Case Study Analysis and Care Planning

Weighting: 45%

Word Count: 3000 words (+/- 10%)

Due Date: Week 12, Friday 5:00 PM AEST

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ASSIGNMENT BRIEF

This assessment requires you to demonstrate advanced understanding of chronic illness trajectory and palliative care principles through comprehensive analysis of a complex patient case study. You will apply the chronic care model, palliative approach framework, and person-centred care principles to develop holistic, evidence-based nursing interventions that address physical, psychosocial, spiritual, and cultural dimensions of care for a patient with end-stage chronic obstructive pulmonary disease (COPD).

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CASE STUDY SCENARIO

Patient Profile: Mr Robert “Bob” Williams

Mr Robert Williams is a 72-year-old Aboriginal Australian male (he/him pronouns) who has been living with severe chronic obstructive pulmonary disease (COPD) for 18 years. He was recently admitted to the respiratory ward of Alice Springs Hospital following his fourth acute exacerbation this year, presenting with worsening dyspnoea, productive cough with purulent sputum, confusion, and severe fatigue. His wife found him sitting upright in his recliner chair at 0300 hours, struggling to breathe and unable to speak in full sentences.

Current Diagnosis:

• Acute exacerbation of severe COPD (GOLD Stage IV – Very Severe)
• Acute on chronic respiratory failure with Type II respiratory failure
• Community-acquired pneumonia (right lower lobe)
• Acute kidney injury (AKI) secondary to dehydration

Medical and Social History:

Cultural and Social Background:

• Proud Arrernte man from Central Australia
• Strong connection to Country and community
• Traditional knowledge holder and respected Elder
• Speaks Arrernte and English (prefers Arrernte with family)
• Married to June (70 years) for 48 years
• Has 6 adult children (ages 38-52), 17 grandchildren, and 4 great-grandchildren
• Lives in a remote community 80km from Alice Springs
• Recently moved to town to be closer to hospital (significant cultural and emotional distress)
• Extended family visits regularly; family meetings important for decision-making

Employment and Lifestyle History:

• Retired mine worker (30 years in underground mining)
• Significant occupational dust exposure
• Smoking history: 60 pack-years (commenced age 14, ceased 6 years ago)
• Non-drinker for past 20 years (previous significant alcohol use)
• Previously very active: hunting, fishing, teaching culture to young people
• Now bedbound most days, requires assistance with all ADLs

Past Medical History:

• COPD diagnosed 18 years ago (initially moderate, now severe)
• Chronic bronchitis and emphysema
• Cor pulmonale (right-sided heart failure secondary to COPD)
• Pulmonary hypertension
• Type 2 Diabetes Mellitus (diagnosed 25 years ago, poorly controlled)
• Ischaemic heart disease (myocardial infarction 8 years ago)
• Hypertension
• Chronic kidney disease Stage 3b (eGFR 35-40 mL/min)
• Osteoarthritis (bilateral knees, lower back)
• Anxiety and depression (following COPD diagnosis)
• Gastro-oesophageal reflux disease (GORD)
• Previous basal cell carcinoma (face) – excised 3 years ago

Surgical History:

• Coronary artery bypass graft (CABG) x3 vessels (8 years ago)
• Left inguinal hernia repair (15 years ago)
• Multiple skin lesion excisions

Current Medications (Home – Prior to Admission):

• Tiotropium (Spiriva) 18mcg – 1 inhalation daily
• Fluticasone/Salmeterol (Seretide) 500/50mcg – 2 inhalations BD
• Salbutamol (Ventolin) 100mcg – 2 puffs PRN (using 10-12 times daily recently)
• Prednisolone 5mg daily (maintenance dose)
• Azithromycin 500mg three times weekly (prophylactic)
• Frusemide 40mg daily
• Spironolactone 25mg daily
• Ramipril 5mg daily
• Metoprolol 50mg BD
• Aspirin 100mg daily
• Atorvastatin 40mg nocte
• Metformin 500mg BD (recently reduced due to kidney function)
• Omeprazole 20mg daily
• Paracetamol 665mg – 2 tablets QID PRN
• Oxycodone SR 10mg BD (for breathlessness and pain)
• Temazepam 10mg nocte PRN
• Mirtazapine 30mg nocte (for depression and appetite)

Allergies:

• Penicillin (documented anaphylaxis – age 42)
• Codeine (nausea and vomiting)
• Morphine (severe pruritus and hallucinations)

Advanced Care Planning Status:

• Has completed Advance Care Directive (ACD) 6 months ago
• Clear wishes documented: No intubation, no ICU admission, no CPR
• Wishes to die on Country if possible, surrounded by family
• Appointed wife June as substitute decision-maker
• Wants spiritual/cultural support from community Elders
• Copy of ACD in medical record and with General Practitioner

Functional Status Prior to This Admission:

• Modified Barthel Index: 35/100 (severe dependency)
• Requires assistance with all ADLs (showering, dressing, toileting, mobilising)
• Uses wheelchair for mobility outside home
• Uses commode at bedside; occasional incontinence at night
• Relies on home oxygen 3L/min continuous, increasing to 5L during exacerbations
• Home Care Package Level 4 in place
• Wife is primary carer with support from community health nurses (twice weekly)
• Meals on Wheels 5 days per week
• Significant unintentional weight loss: 12kg over past 6 months

Psychosocial and Spiritual Considerations:

• Expresses feeling like “a burden” to family
• Grief about loss of independence and cultural responsibilities
• Misses Country deeply; feels spiritually disconnected from land
• Anxiety about dying away from Country
• Depression scores consistently moderate on PHQ-9 (score 14-16)
• Family reports Bob has spoken about “being ready to go”
• Finds comfort in visits from community Elders and cultural practices
• Traditional smoking ceremonies provide spiritual comfort
• Values family presence and collective decision-making

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ADMISSION ASSESSMENT (Current Presentation)

Time of Admission: 0545 hours
Mode of Arrival: Remote Area Nurse-accompanied ambulance transfer (3-hour journey)

Presenting Symptoms on Arrival:

• Severe dyspnoea at rest, unable to speak full sentences
• Productive cough with thick green sputum (approximately 50mL/day)
• Marked use of accessory muscles, tripod positioning
• Lips pursed breathing noted
• Confusion and disorientation (AMTS 6/10)
• Reported fever and rigors overnight
• Decreased oral intake for 3 days
• Reduced urine output
• Generalised weakness and lethargy
• Chest pain described as “tight” and “heavy” (4/10 severity)
• Overwhelming fatigue

Vital Signs on Admission (0600 hours):

• Blood Pressure: 145/88 mmHg
• Heart Rate: 118 bpm (regular rhythm, sinus tachycardia on monitor)
• Respiratory Rate: 32 breaths/min (laboured, shallow)
• Temperature: 38.7°C (tympanic)
• Oxygen Saturation: 84% on room air → 89% on 4L/min via nasal prongs
• Pain Score: 6/10 (chest tightness and generalised body aches)
• Blood Glucose Level: 14.2 mmol/L
• Weight: 52 kg (usual weight 64kg six months ago; BMI now 17.8 kg/m² – underweight)
• Height: 171 cm

Comprehensive Physical Assessment:

General Appearance:

• Appears frail, cachectic, and chronically unwell
• Skin pale with cyanosis noted on lips and nail beds
• Diaphoretic (sweating profusely)
• Obvious respiratory distress
• Barrel-chested appearance consistent with chronic COPD
• Thin extremities with muscle wasting evident

Respiratory Assessment:

• Inspection: Increased anteroposterior diameter, use of accessory muscles (sternocleidomastoid, scalene), intercostal retractions, pursed-lip breathing
• Palpation: Reduced chest expansion bilaterally, tactile fremitus decreased
• Percussion: Hyperresonance throughout lung fields
• Auscultation:
  • Widespread wheeze bilaterally
  • Coarse crackles right lower lobe
  • Prolonged expiratory phase
  • Diminished breath sounds at bases
• Productive cough with thick, purulent green sputum
• Speaking in 2-3 word sentences only

Cardiovascular Assessment:

• Heart rate regular, no murmurs appreciated
• Elevated jugular venous pressure (JVP) noted at 6cm
• Peripheral oedema: 2+ pitting oedema bilateral ankles extending to mid-calf
• Peripheral pulses present but weak (1+)
• Capillary refill time: 4 seconds
• No chest pain at rest currently

Gastrointestinal Assessment:

• Abdomen soft, non-tender, mildly distended
• Bowel sounds present but hypoactive
• Reports constipation (last bowel motion 4 days ago)
• Dentures present (full upper and lower)
• Poor dentition, dry mucous membranes
• Reports minimal appetite for weeks
• Wife reports Bob eating less than 25% of meals

Genitourinary Assessment:

• Indwelling catheter (IDC) inserted on admission
• Initial urine output: 120mL concentrated, dark amber urine
• Reports decreased urination prior to admission

Neurological Assessment:

• Glasgow Coma Scale: 14 (E4, V4, M6)
• Alert but confused about time and place
• Oriented to person
• Abbreviated Mental Test Score (AMTS): 6/10
• Restless and anxious
• Follows simple commands
• Pupils equal, round, reactive to light (PERRL) – 3mm
• No focal neurological deficits noted

Musculoskeletal Assessment:

• Severe muscle wasting noted throughout
• Limited mobility due to dyspnoea
• Bilateral knee and lower back pain reported (chronic)
• Reduced range of motion due to pain and weakness
• Unable to bear weight without significant assistance

Integumentary Assessment:

• Skin pale, cool to touch on extremities
• Poor skin turgor indicating dehydration
• Pressure area assessment: 3cm x 2cm Stage 2 pressure injury on sacrum (present on admission)
• Skin fragile and thin
• Old surgical scars intact
• No signs of acute skin breakdown elsewhere currently

Psychosocial Assessment:

• Appears withdrawn and fatigued
• Minimal eye contact
• Flat affect observed
• Wife reports Bob has been saying “I’m ready” and “I’m tired of fighting”
• Expressed wish to “go home to Country”
• Family present and supportive (wife and 2 daughters at bedside)
• Culturally appropriate communication maintained

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DIAGNOSTIC INVESTIGATIONS

Arterial Blood Gas (ABG) – on 4L O₂ via nasal prongs:

• pH: 7.32 (7.35-7.45) – acidotic
• PaCO₂: 62 mmHg (35-45) – hypercapnia
• PaO₂: 58 mmHg (80-100) – hypoxaemia
• HCO₃⁻: 32 mmol/L (22-26) – compensated
• BE: +6 (−2 to +2)
• Lactate: 2.8 mmol/L (<2)
• Interpretation: Acute on chronic Type II respiratory failure with partial metabolic compensation

Chest X-Ray (Portable):

• Hyperinflation with flattened diaphragms
• Increased anteroposterior diameter
• Right lower lobe consolidation consistent with pneumonia
• Cardiomegaly present
• No pneumothorax or pleural effusion

ECG:

• Sinus tachycardia, rate 118 bpm
• Right axis deviation
• Evidence of right ventricular hypertrophy
• P pulmonale (peaked P waves) – suggesting cor pulmonale
• No acute ischaemic changes

Blood Results:

Full Blood Count (FBC):

• WCC: 17.2 x 10⁹/L (4-11) – leukocytosis
• Neutrophils: 14.8 x 10⁹/L – elevated
• Haemoglobin: 178 g/L (130-180) – polycythaemia (chronic hypoxia compensation)
• Haematocrit: 0.52 (0.40-0.54)
• Platelets: 285 x 10⁹/L (150-400)

Urea and Electrolytes (UEC):

• Sodium: 148 mmol/L (135-145) – hypernatraemia
• Potassium: 5.2 mmol/L (3.5-5.0) – mild hyperkalaemia
• Urea: 18.5 mmol/L (2.5-8.0) – elevated
• Creatinine: 185 μmol/L (60-110) – elevated (baseline 140-150)
• eGFR: 28 mL/min/1.73m² (<30 indicates Stage 4 CKD) – acute deterioration

Liver Function Tests (LFTs):

• All within normal limits

Inflammatory Markers:

• C-Reactive Protein (CRP): 156 mg/L (<5) – significantly elevated
• Procalcitonin: 2.8 ng/mL (<0.5) – elevated, suggesting bacterial infection

Cardiac Markers:

• Troponin I: 0.02 ng/mL (<0.04) – negative
• BNP: 680 pg/mL (<100) – elevated (consistent with heart failure)

Glucose and Metabolism:

• Blood Glucose: 14.2 mmol/L (4-6 fasting)
• HbA1c: 9.2% (target <7% for older adults with diabetes)
• Albumin: 28 g/L (35-50) – hypoalbuminaemia (malnutrition)

Sputum Culture (Preliminary):

• Pending full culture and sensitivity
• Gram stain: Gram-positive cocci in clusters seen

Urinalysis:

• Appearance: Dark, concentrated
• Specific gravity: 1.030 (elevated – dehydration)
• Protein: Trace
• Blood: Negative
• Leukocytes: Negative
• Ketones: Trace

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MEDICAL MANAGEMENT PLAN

Immediate Interventions (0600-0800 hours):

Respiratory Support:

1. Oxygen therapy: 4L/min via nasal prongs to maintain SpO₂ 88-92% (target for COPD with CO₂ retention)
2. Nebulised bronchodilators:
   • Salbutamol 5mg + Ipratropium 500mcg via nebuliser every 4 hours
3. Non-invasive ventilation (NIV) considered but deferred based on:
   • Patient’s Advance Care Directive (no escalation of respiratory support)
   • Discussion with patient and family
   • Documented ceiling of care

Antibiotic Therapy:

• IV Ceftriaxone 1g daily (penicillin allergy noted – cephalosporin safe after specialist review)
• IV Azithromycin 500mg daily for 3 days
• Duration: 7-10 days total, may convert to oral if improving

Corticosteroid Therapy:

• IV Hydrocortisone 100mg QID for 48 hours
• Then oral Prednisolone 30mg daily for 5 days, then wean

Fluid Resuscitation:

• IV Normal Saline 1000mL over 6 hours (cautious given heart failure)
• Strict fluid balance monitoring
• Daily weights

Symptom Management:

• Oxycodone IR 2.5mg PO/SC 4-hourly for breathlessness and pain (morphine allergy noted)
• Paracetamol 1g QID regular
• Midazolam 2.5mg SC PRN for anxiety/agitation (if oxycodone inadequate)
• Hyoscine butylbromide 20mg SC PRN for respiratory secretions

Cardiovascular Support:

• Continue home cardiac medications (frusemide, spironolactone, ramipril, metoprolol)
• Monitor for fluid overload

Diabetes Management:

• Cease metformin (AKI)
• NovoRapid insulin sliding scale for BGL >10 mmol/L
• Monitor BGL QID

Nutritional Support:

• Dietitian referral – urgent
• High protein, high calorie supplements
• Small frequent meals
• Culturally appropriate food (family bringing traditional foods)

Bowel Management:

• Docusate sodium 100mg BD + Senna 2 tablets nocte
• Glycerol suppository PRN if no bowel motion in 3 days

Monitoring Requirements:

1. Continuous pulse oximetry monitoring
2. Cardiac monitoring (telemetry)
3. Vital signs: Hourly for first 6 hours, then 4-hourly if stable
4. Fluid balance: Strict input/output charting
5. Daily weights
6. Blood glucose monitoring: QID pre-meals and bedtime
7. Repeat ABG in 4 hours or if clinical deterioration
8. Repeat UEC and creatinine in 24 hours
9. Neurological observations: 4-hourly (confusion noted)

Multidisciplinary Team (MDT) Involvement:

Referrals Made:

1. Palliative Care Team – urgent referral (same day)
   • Assessment for symptom management
   • Goals of care discussion
   • Support for patient and family
   • Advance care planning review
2. Respiratory Physician – consultation requested
   • Review current management
   • Prognosis discussion
   • Ventilation options (within ACD parameters)
3. Dietitian – urgent referral
   • Nutritional assessment
   • Oral nutrition support plan
   • Consider supplementation
4. Physiotherapist – referral
   • Gentle mobilisation if appropriate
   • Breathing exercises
   • Chest physiotherapy
   • Secretion management
5. Occupational Therapist – referral
   • ADL assessment
   • Equipment needs
   • Discharge planning
6. Social Work – referral
   • Family support
   • Discharge coordination
   • Liaison with remote community services
   • Financial support assessment
7. Aboriginal Health Worker – already involved
   • Cultural support and liaison
   • Family communication
   • Traditional healing practices facilitation
   • Community connections
8. Spiritual Care Services – referral as per patient/family wishes
   • Chaplaincy services offered
   • Facilitation of Elder visits
   • Cultural ceremonies as appropriate

Prognosis and Goals of Care Discussion:

Specialist Respiratory Review Findings (Day 2):

• COPD GOLD Stage IV with acute exacerbation
• Predicted FEV1 <30% based on previous spirometry
• Multiple exacerbations requiring hospitalisation (4 this year alone)
• Progressive decline despite optimal medical therapy
• Cor pulmonale with decompensation
• Significant comorbidities complicating management
• Surprise Question: “Would you be surprised if this patient died within the next 12 months?” Answer: No

Estimated Prognosis:

• Likely prognosis: 3-6 months
• High risk of mortality with current exacerbation
• Each subsequent exacerbation likely to be more severe
• Quality of life significantly impaired

Goals of Care Meeting (Day 3):

• Attendees: Mr Williams (Bob), wife June, 2 daughters, Aboriginal Health Worker, Palliative Care Consultant, Respiratory Physician, Primary Nurse, Social Worker
• Patient’s expressed wishes:
  • Focus on comfort and quality of remaining life
  • No ICU, no intubation, no CPR (as per ACD)
  • Wants to return to Country to die if possible
  • Family support paramount
  • Cultural practices respected
  • Open communication about prognosis
  • Pain and breathlessness well-controlled
  • Dignity and cultural identity maintained

Agreed Management Plan:

• Primary goal: Comfort and symptom management
• Palliative approach to all care
• Treat current exacerbation with antibiotics and supportive care
• No escalation beyond current interventions
• If deteriorates: focus on comfort measures only
• Discharge planning to include:
  • Community palliative care services
  • Remote Area Nurse support
  • Equipment for home (oxygen, hospital bed, medications)
  • Family education and support
  • Potential transfer to Country with appropriate support if stable enough
• Regular family meetings
• Ongoing cultural support
• Advance care planning reinforced and documented in medical record

Current Ceiling of Care:

• Ward-level care only
• No ICU transfer
• No intubation
• No cardiopulmonary resuscitation
• Symptomatic treatment focused on comfort
• Antibiotics appropriate for current infection
• If respiratory failure worsens: focus on symptom relief with opioids and benzodiazepines

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ASSESSMENT REQUIREMENTS

Complete the following tasks based on Mr Williams’ case study. Your responses must demonstrate evidence-based practice, cultural safety, palliative care principles, and holistic person-centred care.

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SECTION A: Chronic Illness Trajectory and Palliative Approach (600 words)

Question 1: Chronic Illness Trajectory Analysis (300 words)

Using the Chronic Care Model and illness trajectory framework:

• Identify and describe which phase of the chronic illness trajectory Mr Williams is currently experiencing
• Discuss how COPD progression follows a specific trajectory pattern (compared to cancer or organ failure trajectories)
• Explain the key indicators that suggest Mr Williams has transitioned to the end-stage of his chronic illness
• Justify why a palliative approach is appropriate at this stage, even while continuing disease-modifying treatments

Question 2: Palliative Care Principles Application (300 words)

Discuss how the following palliative care principles apply to Mr Williams’ care:

• Early integration of palliative care in chronic illness management
• Holistic assessment addressing physical, psychological, social, and spiritual domains
• Open and honest communication about prognosis and goals of care
• The concept of “ceiling of care” and how it aligns with patient autonomy and advance care directives
• Support current evidence-based literature (minimum 3 peer-reviewed sources from 2019-2025)

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SECTION B: Comprehensive Holistic Assessment (700 words)

Question 3: Physical Symptom Assessment and Burden (350 words)

Conduct a comprehensive analysis of Mr Williams’ physical symptom burden:

• Identify and prioritize the SIX (6) most distressing physical symptoms based on the case study
• For each symptom, explain:
  • The underlying pathophysiology causing the symptom
  • How it impacts Mr Williams’ quality of life and functional status
  • The relationship between symptoms (e.g., how dyspnoea affects nutrition, mobility, anxiety)
• Discuss the concept of “total symptom burden” in chronic respiratory illness
• Support with evidence-based literature

Question 4: Psychosocial and Spiritual Assessment (350 words)

Analyze the psychosocial and spiritual dimensions of Mr Williams’ illness experience:

• Discuss the psychological impact of:
  • Loss of independence and role changes
  • Displacement from Country and cultural disconnection
  • Anticipatory grief for self and family
  • Depression and anxiety in the context of advanced COPD
• Examine the spiritual and cultural considerations:
  • Significance of connection to Country for Aboriginal Australians
  • Importance of cultural practices and Elder support
  • Collective family decision-making in Aboriginal culture
  • Spiritual preparation for death
• Explain how nurses can provide culturally safe, trauma-informed care in this context
• Reference relevant cultural safety frameworks and guidelines

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SECTION C: Ethical and Legal Considerations (400 words)

Question 5: Advance Care Planning and Decision-Making (200 words)

Discuss the ethical and legal aspects of Mr Williams’ advance care directive:

• Explain the purpose and legal standing of Advance Care Directives in Australia
• Discuss how the documented ceiling of care (no ICU/intubation/CPR) should be respected and implemented
• Analyze potential ethical tensions between:
  • Respecting patient autonomy vs. family wishes if they differ
  • Active treatment (antibiotics/steroids) vs. comfort-only care
  • Medical futility vs. patient/family hope
• Explain the nurse’s role in advocating for the patient’s documented wishes

Question 6: Cultural Safety and Self-Determination (200 words)

Critically reflect on cultural safety in end-of-life care for Aboriginal Australians:

• Discuss the historical context of mistrust in healthcare systems among Aboriginal people
• Explain the concept of “cultural safety” beyond cultural awareness or sensitivity
• Analyze how healthcare providers can honor Mr Williams’ wishes to die on Country while ensuring safe, supportive care
• Discuss the importance of Aboriginal Health Workers in bridging cultural gaps
• Reference relevant frameworks (e.g., NCCSF – National Cultural Competency and Safety Framework)

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SECTION D: Evidence-Based Symptom Management (800 words)

Question 7: Respiratory Symptom Management (400 words)

Develop a comprehensive evidence-based plan for managing Mr Williams’ breathlessness:

Part A: Non-Pharmacological Interventions (200 words)

• Describe FOUR (4) evidence-based non-pharmacological strategies:
  1. Positioning and breathing techniques
  2. Environmental modifications (temperature, airflow, reducing anxiety triggers)
  3. Energy conservation and pacing activities
  4. Psychological support and anxiety management
• For each intervention provide:
  • Specific implementation details
  • Rationale with evidence-based support (cite literature)
  • Evaluation criteria – how will you measure effectiveness?

Part B: Pharmacological Interventions (200 words)

• Discuss the use of opioids (oxycodone) for refractory breathlessness in COPD:
  • Mechanism of action for breathlessness relief
  • Appropriate dosing strategies in opioid-tolerant patients
  • Why morphine alternatives (oxycodone) are used in this case
  • Monitoring for adverse effects and efficacy
• Discuss the role of benzodiazepines (midazolam) for anxiety-related dyspnoea
• Provide evidence-based rationales with citations

Question 8: Nutrition and Cachexia Management (400 words)

Address Mr Williams’ significant weight loss and malnutrition:

Part A: Pathophysiology and Impact (150 words)

• Explain the pathophysiology of cachexia in advanced COPD:
  • Increased metabolic demands
  • Inflammatory processes
  • Reduced intake due to dyspnoea and early satiety
  • Psychological factors (depression, fatigue)
• Discuss how malnutrition impacts:
  • Respiratory muscle strength and function
  • Immune function and infection risk
  • Wound healing (pressure injury)
  • Overall prognosis and quality of life

Part B: Nursing Interventions (250 words) Develop FOUR (4) evidence-based interventions to optimize nutrition:

1. Nutritional supplementation strategy
   • Rationale: (evidence-based explanation with citation)
   • Evaluation: (specific measurable outcomes)
2. Meal modification and timing
   • Rationale: (evidence-based explanation with citation)
   • Evaluation: (specific measurable outcomes)
3. Appetite stimulation approaches
   • Rationale: (evidence-based explanation with citation)
   • Evaluation: (specific measurable outcomes)
4. Family and cultural food incorporation
   • Rationale: (evidence-based explanation with citation)
   • Evaluation: (specific measurable outcomes)

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SECTION E: Comprehensive Nursing Care Plans (1000 words)

Question 9: Priority Nursing Diagnoses and Care Plans

Develop FOUR (4) comprehensive, evidence-based nursing care plans using the nursing process framework. Each care plan should be approximately 250 words.

Care Plan Structure for Each (250 words each = 1000 words total):

a) Nursing Diagnosis:

• State the priority nursing diagnosis using NANDA-I format where applicable
• Include related factors and defining characteristics specific to Mr Williams

b) Patient-Centered Goals:

• State ONE short-term goal (within 48-72 hours)
• State ONE long-term goal (within 1-2 weeks or discharge)
• Goals must be SMART (Specific, Measurable, Achievable, Relevant, Time-bound)

c) THREE (3) Evidence-Based Nursing Interventions:

• Describe specific, detailed nursing interventions
• Each intervention must include:
  • Rationale: Evidence-based explanation supported by scholarly literature (include in-text citation)
  • Evaluation criteria: Specific, measurable indicators of intervention effectiveness

Priority Areas to Address (Select 4):

1. Impaired Gas Exchange related to ventilation-perfusion imbalance and alveolar-capillary membrane changes
   • Focus on respiratory monitoring, oxygen therapy, positioning, early recognition of deterioration
2. Ineffective Breathing Pattern related to respiratory muscle fatigue and decreased lung compliance
   • Focus on breathing techniques, energy conservation, non-invasive respiratory support
3. Imbalanced Nutrition: Less Than Body Requirements related to dyspnoea, fatigue, and anorexia
   • Focus on nutritional strategies, supplementation, cultural food preferences
4. Anxiety related to breathlessness, fear of suffocation, and approaching death
   • Focus on psychological support, anxiolytic use, presence, communication
5. Impaired Physical Mobility related to severe dyspnoea, fatigue, and deconditioning
   • Focus on safe mobilisation, ADL assistance, pressure injury prevention
6. Risk for Spiritual Distress related to disconnection from Country and approaching death
   • Focus on cultural support, Elder access, traditional practices, family involvement
7. Grieving related to anticipatory loss and declining functional status
   • Focus on therapeutic communication, family support, legacy work, life review
8. Risk for Caregiver Role Strain (wife June) related to complexity of care needs and emotional burden
   • Focus on carer support, respite, education, resource connection

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SECTION F: Discharge Planning and Community Palliative Care (500 words)

Question 10: Comprehensive Discharge Planning (500 words)

Assuming Mr Williams stabilizes sufficiently for discharge to community, develop a comprehensive discharge plan addressing:

Part A: Community Support Services (200 words)

• Identify and describe the key community services required:
  • Community palliative care team role and frequency of visits
  • Remote Area Nurse support and coordination
  • Aboriginal Health Worker involvement
  • GP and specialist follow-up arrangements
  • After-hours support and emergency contacts
  • Allied health services (physiotherapy, occupational therapy, dietitian)
• Discuss specific challenges of providing palliative care in remote Aboriginal communities
• Describe strategies to ensure continuity of care and cultural safety

Part B: Equipment and Medication Management (150 words)

• List essential equipment needed for home management:
  • Oxygen therapy setup (stationary concentrator,

    portable cylinders)

    • Hospital bed with pressure-relieving mattress
    • Commode and shower chair
    • Nebuliser machine
    • Subcutaneous medication delivery system (if appropriate)
    • Develop a medication management plan:
      • Simplified medication regimen
      • PRN medication access (breakthrough breathlessness, anxiety)
      • Storage and administration education for family
      • Webster pack or dosette box arrangements
      • Regular medication review schedule

    Part C: Family Education and Carer Support (150 words)

    • Outline key education topics for Mrs Williams and family:
      • Recognition of deterioration signs requiring medical review
      • Management of acute breathlessness episodes
      • Safe medication administration (including subcutaneous if prescribed)
      • Positioning and comfort measures
      • What to expect as illness progresses (anticipatory guidance)
      • When to call for help vs. comfort measures at home
      • Cultural and spiritual care practices
    • Discuss carer support strategies:
      • Respite care options
      • Carer support groups
      • Psychological support services
      • Financial assistance programs
      • Connection with local Aboriginal community support organizations

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    ASSESSMENT CRITERIA & MARKING RUBRIC

    Criteria	Weight	HD (85-100%)	D (75-84%)	C (65-74%)	P (50-64%)	F (<50%)
    Chronic Illness Trajectory & Palliative Approach	15%	Demonstrates sophisticated understanding of illness trajectories with exceptional integration of palliative care principles and evidence	Strong understanding with comprehensive integration of palliative concepts	Adequate understanding with appropriate application of concepts	Basic understanding with limited depth	Limited or inaccurate understanding
    Holistic Assessment: Physical, Psychosocial, Spiritual	20%	Exceptional depth of holistic assessment demonstrating cultural safety and advanced clinical reasoning	Comprehensive holistic assessment with strong cultural considerations	Adequate assessment covering key domains	Basic assessment with limited holistic approach	Superficial or culturally unsafe assessment
    Ethical & Legal Considerations	10%	Sophisticated analysis of ethical principles, legal frameworks, and cultural safety with critical reflection	Strong analysis with appropriate application of ethical and legal concepts	Adequate discussion of key ethical and legal issues	Basic understanding with limited critical analysis	Limited or inappropriate understanding
    Evidence-Based Symptom Management	20%	Exemplary symptom management strategies with strong evidence base, innovative approaches, and cultural appropriateness	Comprehensive strategies with good evidence support	Adequate strategies with appropriate evidence	Basic strategies with limited evidence	Inadequate or unsafe strategies
    Nursing Care Plans	25%	Exceptional care plans: comprehensive, evidence-based, culturally safe, with sophisticated rationales and specific evaluation criteria	Comprehensive care plans with strong evidence base and clear evaluation	Adequate care plans with appropriate interventions and evaluation	Basic care plans with limited evidence or specificity	Inadequate, inappropriate, or unsafe care plans
    Discharge Planning	10%	Exceptional discharge plan demonstrating advanced understanding of community palliative care, cultural needs, and remote health challenges	Comprehensive discharge plan with strong consideration of community resources and cultural factors	Adequate discharge plan covering key elements	Basic discharge plan with limited detail	Inadequate or unrealistic discharge plan

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    ACADEMIC REQUIREMENTS

    Formatting:

    • Use APA 7th edition referencing style throughout
    • 12-point font (Calibri, Arial, or Times New Roman)
    • 1.5 or double line spacing
    • 2.54cm margins on all sides
    • Include title page with:
      • Student name and ID
      • Unit code and title (NURS4023 Chronic Illness and Palliative Care Nursing)
      • Assignment title
      • Word count
      • Date of submission
    • Number all pages (excluding title page and reference list)
    • Use clear headings matching assessment sections (A, B, C, D, E, F)
    • Subheadings within sections encouraged for clarity

    Academic Integrity:

    • All work must be original and your own
    • Appropriately cite and reference all sources using APA 7th edition
    • Direct quotes should be minimal (maximum 3 short quotes in entire paper)
    • Paraphrase and synthesize information, demonstrating your understanding
    • Use Turnitin similarity report as guide (similarity <20% expected, excluding reference list)
    • AI-generated content must be acknowledged if used for ideation only
    • Note: AI cannot be used to generate content for submission; use only for brainstorming or clarifying concepts

    Evidence Base:

    • Minimum of 20 scholarly references required
    • At least 15 must be peer-reviewed journal articles published 2019-2025
    • Include relevant Australian and international clinical practice guidelines:
      • Palliative Care Australia guidelines
      • COPD-X Australian and New Zealand Guidelines
      • Lung Foundation Australia resources
      • Therapeutic Guidelines: Palliative Care
      • Cultural safety frameworks (NCCSF, CATSINAM guidelines)
    • Maximum 5 clinical guidelines/policy documents
    • Avoid non-scholarly websites, Wikipedia, and non-peer-reviewed sources
    • Textbooks may be used sparingly (maximum 2-3) for foundational concepts
    • Grey literature from reputable sources (government health departments, professional organizations) acceptable in limited amounts

    Cultural Safety Requirements:

    • Mandatory: This assignment requires demonstration of cultural safety principles when caring for Aboriginal and Torres Strait Islander peoples
    • Use appropriate terminology: “Aboriginal and Torres Strait Islander peoples” or specific nation/language groups
    • Acknowledge historical trauma and healthcare system distrust
    • Demonstrate understanding of cultural protocols (family decision-making, connection to Country, spiritual practices)
    • Reference relevant cultural competency frameworks and guidelines
    • Avoid cultural stereotyping or deficit-based language
    • Use strengths-based approaches
    • Engage with Aboriginal and Torres Strait Islander authored literature where possible

    Submission:

    • Submit via Canvas LMS before deadline: Week 12, Friday 5:00 PM AEST
    • Save file as: StudentSurname_StudentID_NURS4023_Assessment2.docx
      • Example: Williams_12345678_NURS4023_Assessment2.docx
    • Late submissions: 5% penalty per calendar day unless approved extension granted
    • Extensions: Apply via Student Services minimum 48 hours before due date with supporting documentation
    • Special consideration: Available for unforeseen circumstances (medical, compassionate grounds)

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    LEARNING OUTCOMES ADDRESSED

    This assessment enables you to demonstrate achievement of the following unit learning outcomes:

    1. LO1: Apply advanced knowledge of chronic illness trajectories and the transition to palliative care across diverse populations
    2. LO2: Demonstrate comprehensive understanding of palliative care philosophy, principles, and evidence-based symptom management
    3. LO3: Conduct holistic assessment addressing physical, psychological, social, spiritual, and cultural dimensions of care
    4. LO4: Develop evidence-based, person-centred care plans that integrate curative, chronic disease management, and palliative approaches
    5. LO5: Apply ethical and legal frameworks in end-of-life care, including advance care planning and substitute decision-making
    6. LO6: Demonstrate cultural safety and trauma-informed practice when providing palliative care to Aboriginal and Torres Strait Islander peoples
    7. LO7: Collaborate effectively within multidisciplinary teams to provide seamless, coordinated palliative care
    8. LO8: Plan comprehensive discharge and community support for patients with advanced chronic illness

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    RESOURCES & SUPPORT

    Essential Readings:

    • COPD-X Australian and New Zealand Guidelines (Version 2.73, 2024)
    • Palliative Care Australia. (2023). National Palliative Care Standards (5th edition)
    • Therapeutic Guidelines: Palliative Care (Version 5, 2023)
    • CRANAplus. (2024). Remote Primary Health Care Manuals
    • Nursing and Midwifery Board of Australia. (2020). Code of Conduct for Nurses
    • National Aboriginal Community Controlled Health Organisation (NACCHO). (2024). Cultural safety resources
    • Unit required textbooks and prescribed readings on Canvas

    Recommended Databases for Literature Searching:

    • CINAHL Complete (Nursing and Allied Health Database)
    • PubMed/MEDLINE (Medical and health sciences)
    • Cochrane Library (Systematic reviews and evidence synthesis)
    • Joanna Briggs Institute (JBI) EBP Database (Evidence summaries)
    • PsycINFO (Psychology and mental health)
    • Informit Health Collection (Australian and New Zealand health literature)
    • Google Scholar (Supplementary searching)

    Key Australian Organizations and Guidelines:

    • Palliative Care Australia: www.palliativecare.org.au
    • Lung Foundation Australia: www.lungfoundation.com.au
    • Australian Commission on Safety and Quality in Health Care (ACSQHC) – National Consensus Statement on End-of-Life Care
    • Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM): www.catsinam.org.au
    • Australian Healthcare and Hospitals Association (AHHA) – Aboriginal and Torres Strait Islander health
    • Australian Indigenous HealthInfoNet: www.healthinfonet.ecu.edu.au

    Support Services:

    • Academic Learning Advisors: Writing support, academic skills development, assignment structure guidance
    • Librarians: Database searching, literature review support, referencing assistance
    • Aboriginal and Torres Strait Islander Student Support: Cultural support, academic guidance, connection to community
    • Disability Liaison Officers: Accessibility and reasonable adjustment support
    • Student Wellbeing Services: Counselling, mental health support
    • Peer Assisted Study Sessions (PASS): Peer-led study groups

    Additional Resources:

    • Cultural Safety Learning Modules available on Canvas
    • Palliative Care case study videos demonstrating symptom assessment and management
    • Communication skills workshops for difficult conversations and goals of care discussions
    • Reflective practice guidelines for cultural safety development

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    IMPORTANT NOTES

    Palliative Care Content Warning:

    This case study involves end-of-life care, terminal illness, and discussions of death and dying. If you find this content distressing or triggering, please:

    • Contact your unit coordinator to discuss alternative assessment arrangements if needed
    • Access Student Wellbeing Services for support
    • Connect with your cultural support networks
    • Practice self-care throughout this assessment period

    Cultural Safety Statement:

    This unit is committed to providing culturally safe learning experiences for all students. The case study has been developed in consultation with Aboriginal health professionals and is intended to promote understanding of culturally safe palliative care. If you have concerns about cultural content or representation, please contact your unit coordinator.

    Work Integrated Learning (WIL) Connection:

    Students are encouraged to reflect on their clinical placement experiences when completing this assessment. If you have cared for patients with chronic respiratory illness or palliative care needs, draw on these experiences while maintaining patient confidentiality (de-identify all information).

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    SUGGESTED REFERENCES & BIBLIOGRAPHY

    Credible, Peer-Reviewed References (2019-2025):

    1. Brighton, L. J., Miller, S., Farquhar, M., Booth, S., Yi, D., Gao, W., & Murtagh, F. E. M. (2019). Holistic services for people with advanced disease and chronic breathlessness: A systematic review and meta-analysis. Thorax, 74(3), 270-281. https://doi.org/10.1136/thoraxjnl-2018-211589

    2. Geense, W. W., van de Glind, E. M., Vissers, K. C., & Burger, D. M. (2021). Pharmacological treatment of cancer pain, neuropathic pain, breathlessness and cough in palliative care: A systematic review. Journal of Pain and Symptom Management, 61(6), 1254-1280. https://doi.org/10.1016/j.jpainsymman.2020.11.028

    3. Lovell, N., Bajwah, S., Maddocks, M., Sidhu, P. S., Bradshaw, A., Hocaoglu, M., Fraser, L. M., Oluyase, A. O., Dunleavy, L., Chambers, R., Ellis-Smith, C., Noreik, M., Murtagh, F. E. M., Higginson, I. J., & Sleeman, K. E. (2021). Use of advance care planning and preferences of patients with chronic respiratory disease for care at the end-of-life: A mixed methods systematic review. Respiratory Research, 22(1), Article 25. https://doi.org/10.1186/s12931-021-01622-6

    4. McGrath, P., Holewa, H., & Ogilvie, K. (2020). Insights from an Australian focus group study on palliative care for Aboriginal peoples: Nurse practice implications. BMC Palliative Care, 19(1), Article 164. https://doi.org/10.1186/s12904-020-00673-y

    5. Smallwood, N., Philip, J., Gorelik, A., Irving, L., & Johnson, M. (2022). Practical management of chronic breathlessness in advanced chronic obstructive pulmonary disease: A multidisciplinary approach. Chronic Respiratory Disease, 19, 1-14. https://doi.org/10.1177/14799731221075344

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    FOUR POTENTIAL TITLES FOR THE PAPER:

    1. SEO-Optimized Title:
    “Evidence-Based Nursing Care and Holistic Palliative Management for Aboriginal Patient with End-Stage COPD: Comprehensive Case Study Analysis Integrating Cultural Safety, Symptom Control, and Advance Care Planning in Remote Australian Healthcare Context”

    2. 3-5 Word Topic Sentence:
    “End-Stage COPD Palliative Care”

    3. 4-8 Word Topic Sentence (Option 1):
    “Cultural Safety in Aboriginal End-of-Life Respiratory Care”

    4. 4-8 Word Topic Sentence (Option 2):
    “Holistic Management of Advanced COPD with Palliative Approach”

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    5 RELEVANT KEYWORDS/KEY PHRASES FOR POST META TAGS:

    chronic obstructive pulmonary disease palliative care, end-stage COPD symptom management, Aboriginal cultural safety end-of-life care, advance care planning respiratory disease, holistic nursing assessment chronic illness

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    ASSESSMENT SUBMISSION CHECKLIST

    Before submitting your assignment, ensure you have:

    • ☐ Completed all sections (A through F) as required
    • ☐ Met word count requirements (3000 words +/- 10% = 2700-3300 words)
    • ☐ Included minimum 20 references (at least 15 peer-reviewed articles 2019-2025)
    • ☐ Used APA 7th edition referencing correctly throughout (in-text citations and reference list)
    • ☐ Demonstrated cultural safety principles and appropriate terminology
    • ☐ Supported all clinical statements with evidence-based literature
    • ☐ Included title page with all required information
    • ☐ Used appropriate academic writing style (third person, formal tone)
    • ☐ Proofread for spelling, grammar, and clarity
    • ☐ Checked Turnitin similarity score (<20% excluding reference list)
    • ☐ Saved file with correct naming convention
    • ☐ Submitted before deadline via Canvas LMS

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    FREQUENTLY ASKED QUESTIONS (FAQs)

    Q1: Can I use first-person (“I”) when discussing nursing interventions?
    A: No. Use third-person perspective: “The nurse will…” or “Nursing staff should…” to maintain academic writing standards.

    Q2: How many references should each section include?
    A: Distribute references throughout. Sections requiring evidence-based rationales (D and E) should have the most citations. Aim for at least 1-2 citations per major point.

    Q3: Can I use direct quotes from guidelines or literature?
    A: Minimal quotes only (maximum 3 short quotes in entire paper). Paraphrase and synthesize information to demonstrate your understanding.

    Q4: What if I haven’t had clinical experience with COPD or palliative care patients?
    A: This is an academic exercise. Use the case study information provided and scholarly literature to complete the assignment. Clinical experience is beneficial but not essential.

    Q5: How detailed should the care plans be?
    A: Each care plan should be approximately 250 words and include: nursing diagnosis, 2 goals (short and long-term), 3 detailed interventions each with rationale (cited) and evaluation criteria.

    Q6: Can I include diagrams, tables, or appendices?
    A: Tables may be used if they enhance clarity (e.g., care plan format) and are included in word count. Appendices are not required or recommended. Diagrams should be minimal and professional.

    Q7: What constitutes “cultural safety” in this assignment?
    A: Cultural safety goes beyond awareness. Demonstrate understanding of: historical context of Aboriginal health, healthcare system mistrust, importance of Country and cultural practices, family-centered decision-making, trauma-informed approaches, and self-reflection on power dynamics.

    Q8: How current should clinical guidelines be?
    A: Use the most current version available. COPD-X guidelines are updated regularly. Palliative care guidelines should be within last 5 years. Journal articles should prioritize 2019-2025.

    Q9: What if I disagree with the medical management in the case study?
    A: This is a learning exercise. Work with the scenario provided. You may briefly note alternative approaches if evidence-based, but focus your response on answering the questions asked.

    Q10: Can I get an extension if I’m finding the content emotionally difficult?
    A: Yes. Contact Student Services or your unit coordinator as early as possible. Extensions for compassionate/medical grounds require supporting documentation. Wellbeing support services are available.

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    CONCLUSION

    This case study assessment provides an opportunity to integrate theoretical knowledge with practical application in chronic illness and palliative care nursing. Mr Williams’ case represents the complex, multifaceted nature of end-stage COPD management, requiring you to demonstrate advanced clinical reasoning, cultural competency, ethical practice, and evidence-based care planning.

    Throughout this assignment, remember that palliative care is not simply about end-of-life care, but about optimizing quality of life at any stage of serious illness. Your role as a nurse extends beyond physical symptom management to encompass psychological support, cultural safety, family care, and advocacy for patient autonomy and dignity.

    This assessment challenges you to think holistically, critically, and compassionately about a vulnerable patient population. Your learning through this process will enhance your capacity to provide person-centred, culturally safe, evidence-based care to patients with chronic life-limiting illnesses.

    Good luck with your assignment. Your dedication to learning excellence in palliative and chronic illness nursing is valued and appreciated.

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    END OF ASSIGNMENT BRIEF

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    Document Information:

    • Created: October 2025
    • Unit Coordinator: [Name withheld for template purposes]
    • School: School of Nursing and Healthcare
    • Faculty: Faculty of Health Sciences
    • Institution: