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Assessment 1: case report link by the assessment due date. Relevance: In order to plan and provide optimal person-centred nursing care, Registered nurses need to be able to interpret clinical information and draw upon their knowledge of pathophysiology and evidence-based clinical practice. Therefore, the purpose of this assessment is to support the development of the skills needed to evaluate evidence and to develop reflection and clinical reasoning skills. What you need to do: Based upon the clinical scenario provided below, construct a case report which is a detailed report of the client’s clinical presentation, nursing diagnosis and inter-professional plan of care. The case report will draw upon your knowledge of pathophysiology, pharmacology and relevant academic literature to support an evidence-based plan of care. The case report must be presented using the headings provided below. A description of the content for each section of the report has been provided. It is important that all sections of the report are conceptually connected. For example, your knowledge of pathophysiology and pharmacology, and your understanding of this particular client, should underpin the nursing problems that you identify which should, in turn, drive the inter-professional plan of care that is relevant for this clinical scenario. Case Report: The case report must include the following: Introduction Using the ISBAR clinical handover framework, introduce the client and provide a brief overview of their case. Provide an outline of the purpose and structure of the report. Primary medical diagnosis Identify the primary medical diagnosis for the client (i.e. Diabetic Retinopathy). Provide a brief description of the pathophysiology of Diabetic Retinopathy, with clear links to the case scenario. Support this discussion using current literature (last 10 years). Medication management  Identify the current medications prescribed for the client. Provide a brief description of the medications (i.e. mechanism of action, indication, side-effects and precautions). Support this discussion using current literature (last 10 years). Nursing diagnoses  (a) Nursing problem related to medical diagnosis Using your knowledge of pathophysiology, document one (1) nursing problem that may arise as a result of the client’s primary medical diagnosis. This problem may be an actual or potential nursing problem. Provide a brief description for why this problem may arise for this client. Support this discussion using current literature (last 10 years). (b) Nursing problem related medication management: Using your knowledge of pharmacology, document one (1) nursing problem that may arise as a result of the client’s current medications. This problem may be an actual or potential nursing problem. Provide a brief description for why this problem may arise for this client. Support this discussion using current literature (last 10 years). Nursing Role and Inter-professional Plan of Care  As the community nurse working as part of the aged care assessment team, discuss how you would facilitate an interprofessional plan of care for this client, with consideration to the two identified nursing diagnoses. Discuss the aim for and importance of using an interprofessional approach. Discuss the role of the Registered nurse to facilitate the interdisciplinary plan of care for this client. Identify the key members of the interprofessional health care team, and the role that they would play, specific to the two identified nursing diagnoses. Support this discussion using current literature (last 10 years). SummarySummarise the major findings of this case report. Referencing The content of the case report must be supported through referencing of current literature and must include a reference list and intext citations. You will be assessed on referencing so make sure to follow the UniSA-Harvard referencing style closely to avoid losing marks. Please refer to the Harvard Referencing System to accurately reference your case report: https://lo.unisa.edu.au/course/view.php?id=3839 Overall writing and presentation This assignment must be saved and submitted as a word document. This case report must be structured using the headings provided and presented using academic writing. The use of dot- points will result in a reduction of marks. You will be assessed on the overall writing and presentation, so make sure that you follow the academic writing guidelines closely to avoid losing marks. Please refer to the UniSA-School of Nursing and Midwifery academic writing guidelines to format your case report Clinical Scenario: As the community nurse for the Aged Care Assessment Team, you have been asked to conduct a home visit to assess Mr Hank Jackson. Mr Hank Jackson is a 64-year-old newly retired truck driver, who has recently been diagnosed with diabetic retinopathy and is legally blind in his left eye. Mr Jackson has a medical history which includes type 2 diabetes mellitus (diagnosed five years ago) and hypertension (diagnosed 7 years ago). Mr Jackson’s doctor has prescribed Metformin 500mg twice daily and Metoprolol 50mg twice daily. Mr Jackson lives alone, in his own home. He is a self-described bachelor, but he has a daughter who lives interstate, from a relationship he had in his 20s. The referral from the General Practitioner (GP) indicates that he has suboptimal blood pressure and diabetes control, despite medication management and recommended dietary control. The last blood pressure recorded was 159mmHg/96mmHg and his glycated haemoglobin (HbA1C) has never been less than 8%. Mr Jackson lives in a single-storey home, with a sunken living room and an outdoor veranda leading to a large, overgrown garden. Each room of the home appears cluttered, with ‘keepsakes’ from overseas travels and old newspapers stacked in piles in each room of the home. On general appearance, Mr Jackson appears overweight and has a flushed facial appearance. He wears glasses for reading and says that he loves to read but has been having trouble recently and describes his vision as ‘patchy and blurred’. On questioning, he does admit to feeling ‘fuzzy in the head’ if he forgets to take his tablets, but otherwise feels that he is in good general health. He states that he has “never been sick a day in my life” and only retired because he lost his drivers’ license due to his impaired vision. Mr Jackson does not routinely test his blood glucose levels at home and expresses doubt that this would help him, saying: “what would knowing the numbers do for me? The doctor already knows the sugars are high”. Mr Jackson has been trying to lose weight for the past 6 months, without success; but feels that he has more time for exercise now that he is retired. Mr Jackson wants to remain in his own home, that he has lived in all his adult life, and takes pride in his cooking and making his own home-brew. He will require an interprofessional community plan of care. 3 How will I get assistance to complete this assessment? Each of the topics delivered in this course will provide content that will give you the knowledge that you will need to successfully complete this assessment. For example, the weekly learning activities to develop the ISBAR plan of care will prepare you to complete the case report. You should make sure that you read all information provided, use opportunities to discuss this assessment in the weekly tutorials or virtual classrooms. In addition, the library will run a workshop (via virtual classroom) to support you to identify relevant sources of literature and the course coordinator will run a workshop (via virtual classroom) to support you to plan and write your case report.

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