NURSING CASE STUDY ASSESSMENT TASK

Unit Code: NURS3042

Unit Title: Advanced Clinical Nursing Practice: Acute Care Management

Assessment Type: Written Case Study Analysis

Weighting: 40%

Word Count: 2500 words (+/- 10%)

Due Date: Week 10, Friday 5:00 PM AEST

ASSIGNMENT BRIEF

This assessment requires you to demonstrate advanced clinical reasoning and evidence-based nursing practice through comprehensive analysis of a complex patient case study. You will apply theoretical knowledge to clinical practice, demonstrating your ability to assess, plan, implement, and evaluate nursing care for an adult patient experiencing an acute neurological event.

CASE STUDY SCENARIO

Patient Profile: Mr Daniel Nguyen

Mr Daniel Nguyen is a 58-year-old Vietnamese-Australian male (he/him pronouns) who was brought to the Emergency Department of Royal Melbourne Hospital via ambulance at 0645 hours after his wife discovered him collapsed in the bathroom. She reported he had complained of a severe headache and dizziness before falling. Mr Nguyen was found with right-sided weakness and incomprehensible speech.

Preliminary Diagnosis: Right-sided Middle Cerebral Artery (MCA) territory ischemic cerebrovascular accident with suspected atrial fibrillation as causative factor.

Medical and Social History:

• Cultural Background: Born in Vietnam, migrated to Australia 35 years ago. Speaks Vietnamese and English. Practices Buddhism.
• Family Composition: Married for 32 years, lives with wife Linh (56 years). Three adult children who live locally. Primary carer for his 85-year-old mother who lives in a granny flat on their property.
• Employment: Recently retired accountant (retired 6 months ago).
• Past Medical History:
  • Hypertension (diagnosed 8 years ago)
  • Hyperlipidaemia (diagnosed 5 years ago)
  • Type 2 Diabetes Mellitus (diagnosed 3 years ago)
  • Atrial fibrillation (newly diagnosed on this admission)
  • Obstructive Sleep Apnoea (diagnosed 18 months ago, CPAP non-compliant)
  • Anxiety disorder (managed with counselling)
• Surgical History: Appendectomy (age 22), Right knee arthroscopy (age 54)
• Current Medications (Home):
  • Irbesartan 150mg daily
  • Atorvastatin 40mg nocte
  • Metformin XR 1000mg BD
  • Aspirin 100mg daily (ceased on admission)
• Allergies: Penicillin (rash), Shellfish (anaphylaxis)
• Social History:
  • Non-smoker (ceased 20 years ago, 15-pack-year history)
  • Alcohol: 2-3 standard drinks, 4-5 times per week
  • Independent with all ADLs prior to admission
  • Drives regularly
  • Active in local Vietnamese community
  • Enjoys gardening and cooking

Admission Assessment Findings (Time: 0715 hours):

Vital Signs:

• BP: 165/95 mmHg (Right arm, lying)
• Heart Rate: 98 bpm (irregular)
• Respiratory Rate: 20 breaths/min
• Temperature: 36.8°C (tympanic)
• SpO₂: 94% on room air
• Blood Glucose Level: 12.3 mmol/L
• Weight: 87 kg
• Height: 172 cm
• BMI: 29.4 kg/m²

Neurological Assessment:

• Glasgow Coma Scale: 14 (E4, V4, M6)
• Alert and oriented to person and place, confused about time
• Left-sided hemiparesis (power 2/5 in upper limb, 3/5 in lower limb)
• Left facial droop with deviation of angle of mouth
• Expressive aphasia (difficulty forming words, frustration evident)
• Receptive language intact (follows simple commands)
• Left-sided visual field deficit (hemianopia)
• Left-sided sensory neglect evident
• PEARL (Pupils Equal and Reactive to Light): 3mm bilaterally
• Dysphagia screening positive (failed water swallow test)

Physical Assessment:

• Cardiovascular: Irregular heart rhythm, no murmurs. Peripheral pulses present bilaterally.
• Respiratory: Clear breath sounds bilaterally, mild use of accessory muscles
• Gastrointestinal: Abdomen soft, non-tender, bowel sounds present
• Genitourinary: Indwelling catheter (IDC) inserted in ED, draining clear yellow urine
• Integumentary: 8cm x 4cm haematoma left temporal region (from fall), 3cm laceration left eyebrow (sutured in ED), skin intact elsewhere
• Musculoskeletal: Decreased muscle tone left side, full range of motion right side

Investigations Completed:

• CT Brain (non-contrast): Right MCA territory infarction, no haemorrhage
• CT Angiography: Patent major vessels, no large vessel occlusion
• ECG: Atrial fibrillation, rate 95-105 bpm
• Chest X-ray: Clear lung fields, normal cardiac silhouette
• Blood Results:
  • Full Blood Count: WCC 9.2, Hb 142, Platelets 245
  • UEC: Na+ 138, K+ 4.1, Creatinine 95, eGFR >60
  • LFTs: Within normal limits
  • Coagulation: INR 1.0, APTT 28 seconds
  • Lipids: Total cholesterol 5.8, LDL 3.9, HDL 0.9, Triglycerides 2.4
  • HbA1c: 7.8%
  • Troponin: Negative

Current Medical Management:

Orders on Admission to Stroke Unit:

1. Strict bedrest for first 24 hours
2. Nil by mouth (NBM) pending Speech Pathology assessment
3. IV Normal Saline 80mL/hour via left forearm cannula (20G)
4. Continuous cardiac monitoring
5. Neurological observations: 1-hourly for 24 hours, then 2-hourly if stable
6. Regular vital signs monitoring
7. Strict input/output charting
8. Blood glucose monitoring: QID pre-meals and bedtime
9. Oxygen therapy: Maintain SpO₂ >95%
10. DVT prophylaxis: Graduated compression stockings, intermittent pneumatic compression devices
11. Pressure injury prevention: Turn 2-hourly, pressure-relieving mattress

Medication Orders:

• Aspirin 300mg stat, then 100mg daily (oral/NG)
• Atorvastatin 80mg nocte (oral/NG)
• Apixaban 5mg BD (oral/NG) – commenced after discussion with stroke neurologist
• Irbesartan 150mg daily (oral/NG) – hold if SBP <130 mmHg
• Metformin 500mg BD (oral/NG) – restart once tolerating diet
• NovoRapid insulin: as per sliding scale for BGL >10 mmol/L
• Paracetamol 1g QID PRN (oral/NG)
• Ondansetron 4mg TDS PRN nausea (oral/NG/IV)
• Docusate sodium 100mg BD (oral/NG)
• Temazepam 10mg nocte PRN sleep (oral/NG)

Multidisciplinary Consultations Requested:

• Speech Pathology (swallowing assessment) – URGENT
• Physiotherapy (mobility and rehabilitation assessment)
• Occupational Therapy (ADL assessment and equipment needs)
• Dietitian (nutritional assessment once oral intake established)
• Social Work (discharge planning, carer support)
• Stroke Rehabilitation Physician (transfer planning)

Discharge Planning Considerations: Mr Nguyen will require 3-4 weeks acute stroke unit management before transfer to inpatient rehabilitation facility. Estimated total length of stay: 6-8 weeks. Significant home modifications will likely be required. Family education regarding stroke, medication management, and ongoing care needs essential.

ASSESSMENT REQUIREMENTS

You are required to complete the following tasks based on Mr Nguyen’s case study:

SECTION A: Clinical Environment Preparation and Initial Assessment (500 words)

1. Room Preparation (150 words):
   • Describe how you would prepare the stroke unit room before Mr Nguyen’s arrival from the Emergency Department
   • Consider safety, equipment placement, cultural considerations, and monitoring requirements
2. Assessment Equipment (150 words):
   • Identify and justify SIX (6) essential pieces of equipment required for ongoing nursing assessment
   • Explain the specific relevance of each piece of equipment to Mr Nguyen’s condition
3. Documentation Standards (200 words):
   • Identify and explain FIVE (5) critical components of accurate nursing documentation in this acute stroke scenario
   • Discuss the legal, professional, and clinical importance of each component

SECTION B: Pathophysiology and Clinical Manifestations (600 words)

4. Cerebrovascular Accident Pathophysiology (300 words):
   • Compare and contrast ischemic and haemorrhagic stroke, including:
     • Underlying pathophysiological mechanisms
     • Location of vascular disruption
     • Causative factors
     • Immediate management differences
   • Support your discussion with current evidence-based literature
5. Right-Sided MCA Stroke Manifestations (300 words):
   • Identify and explain FIVE (5) clinical manifestations specific to right-sided MCA territory stroke
   • Explain why Mr Nguyen’s presenting symptoms are consistent with this diagnosis
   • Discuss the neuroanatomical basis for his presenting symptoms

SECTION C: Comorbidity Impact and Psychosocial Considerations (400 words)

6. Comorbidity Analysis (200 words):
   • Identify Mr Nguyen’s comorbidities and explain how EACH ONE:
     • Contributed to his stroke risk
     • Will impact his acute management
     • May influence his rehabilitation outcomes
7. Psychosocial Impact in Late-Middle Adulthood (200 words):
   • Discuss the potential psychological and social impacts of sudden physical disability on a person in late-middle adulthood (58 years)
   • Consider Mr Nguyen’s specific circumstances: recent retirement, carer responsibilities, cultural background, and family dynamics
   • Support your discussion with relevant developmental and cultural competency literature

SECTION D: Nursing Care Plans (800 words)

8. Evidence-Based Care Plan Development:

Using the nursing process framework, develop FOUR (4) comprehensive care plans addressing Mr Nguyen’s priority nursing diagnoses. For each care plan, provide:

Care Plan Structure (200 words each = 800 words total):

a) Nursing Diagnosis: Clearly state the actual or risk nursing diagnosis using NANDA-I format where appropriate

b) TWO (2) Evidence-Based Nursing Interventions:

• Describe specific, measurable interventions you will implement
• Each intervention must include:
  • Rationale: Evidence-based explanation supported by scholarly literature (include in-text citations)
  • Evaluation criteria: How you will measure the effectiveness of the intervention (specific, measurable, time-framed)

Suggested Priority Areas (choose 4):

• Impaired physical mobility related to left hemiparesis
• Risk for aspiration related to dysphagia
• Impaired verbal communication related to expressive aphasia
• Risk for falls related to left-sided weakness and visual field deficit
• Risk for pressure injury related to immobility and altered sensation
• Risk for venous thromboembolism related to immobility
• Acute confusion related to stroke and unfamiliar environment
• Anxiety related to sudden loss of function and communication difficulties

SECTION E: Clinical Handover Communication (200 words)

9. ISBAR Handover (200 words):

Construct a comprehensive clinical handover using the ISBAR format for Mr Nguyen at the end of your shift (1500 hours). Assume it is now 8 hours post-admission. Your handover should be:

• Concise yet comprehensive
• Prioritized appropriately
• Include relevant updates and pending actions
• Suitable for verbal bedside handover to the incoming nurse

ISBAR Components Required:

• I (Introduction): Identification of patient, room, and admitting diagnosis
• S (Situation): Current clinical status and any changes since admission
• B (Background): Pertinent medical history, medications, allergies, and social circumstances
• A (Assessment): Current assessment findings, vital signs, and clinical concerns
• R (Recommendation): Immediate priorities, pending tasks, and anticipatory guidance

ASSESSMENT CRITERIA & MARKING RUBRIC

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 details, unit code, and assignment title
• Number all pages
• Use clear headings and subheadings matching assessment sections

Academic Integrity:

• All work must be original
• Appropriately cite and reference all sources
• Use Turnitin similarity report as a guide (similarity <20% expected)
• AI-generated content must be acknowledged and is limited to ideation only, not content generation

Evidence Base:

• Minimum of 15 scholarly references required
• Majority (at least 10) must be peer-reviewed journal articles published 2019-2025
• Clinical practice guidelines and policy documents may constitute up to 5 references
• Avoid non-scholarly websites and tertiary sources (textbooks should be minimal)

Submission:

• Submit via Canvas LMS before deadline
• Save file as: StudentSurname_StudentID_NURS3042_A2.docx
• Late submissions: 5% penalty per calendar day unless extension granted
• Extensions: Apply via Student Services at least 48 hours before due date

LEARNING OUTCOMES ADDRESSED

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

1. LO1: Apply advanced clinical reasoning to assess and prioritize care for patients with acute neurological conditions
2. LO2: Demonstrate comprehensive knowledge of pathophysiology and its application to nursing practice
3. LO3: Develop evidence-based nursing care plans using the nursing process framework
4. LO4: Communicate effectively using standardized clinical handover processes
5. LO5: Integrate cultural competency and person-centred principles into nursing practice
6. LO6: Apply current evidence and clinical practice guidelines to acute care nursing

RESOURCES & SUPPORT

Essential Readings:

• Australian Stroke Clinical Guidelines (Stroke Foundation, 2024)
• AHA/ASA Guidelines for Management of Acute Ischemic Stroke (2024)
• Nursing and Midwifery Board of Australia Professional Standards
• Your unit required textbooks and prescribed readings

Recommended Databases:

• CINAHL Complete
• PubMed/MEDLINE
• Cochrane Library
• Joanna Briggs Institute EBP Database

Support Services:

• Academic Learning Advisors (writing support)
• Librarians (research and database searching)
• Disability Liaison Officers (accessibility support)
• Student Wellbeing Services

SUGGESTED REFERENCES & BIBLIOGRAPHY

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

1. Lindgren, E., Bryntesson, A., Tistad, M., von Koch, L., & Guidetti, S. (2022). Experiences of multidisciplinary teamwork in stroke rehabilitation – A qualitative study focusing on working life in Sweden. BMC Health Services Research, 22(1), Article 1175. https://doi.org/10.1186/s12913-022-08563-2
2. Mitchell, C., Bowen, A., Tyson, S., Butterfint, Z., & Conroy, P. (2021). Interventions for dysarthria due to stroke and other adult-acquired, non-progressive brain injury. Cochrane Database of Systematic Reviews, 2021(2), Article CD002088. https://doi.org/10.1002/14651858.CD002088.pub3
3. O’Brien, S. R., Xue, Y., Ingersoll, G., & Kelly, A. (2021). Shorter hospital length of stay associated with use of a standardized mobility assessment in stroke patients: A retrospective study. Archives of Physical Medicine and Rehabilitation, 102(1), 4-9. https://doi.org/10.1016/j.apmr.2020.06.026
4. Rohde, D., Merriman, N. A., Doyle, F., Bennett, K., Williams, D., & Hickey, A. (2019). Does cognitive impairment impact self-management in stroke survivors? A systematic review and meta-analysis. Disability and Rehabilitation, 41(20), 2427-2447. https://doi.org/10.1080/09638288.2018.1469714
5. Zhang, H., Shi, Y., Zhou, L., Shang, M., & Zhao, Y. (2023). Nursing care quality and patient safety culture in stroke units: A cross-sectional study. Journal of Clinical Nursing, 32(15-16), 4785-4795. https://doi.org/10.1111/jocn.16673