The assessment piece should be developed with reference to the clinical reasoning cycle.
- patient’s history, presenting problems and the related pathophysiological processes to identify priority problems
- comprehensive assessment, i.e. specific observation, assessment tools and or tests
- holistic plan of care is developed by setting specific goals
- formulate nursing interventions and or treatments, with rationales and consider ways to evaluate the effectiveness of actions
- consider relevance of specific nursing standards, code of conduct, code of ethics and
- legalities and relevant legislation
- adherence to cultural awareness and diversity considerations
- Consider patient-centred care, recovery-oriented and trauma-informed practice,
- patient/consumer perspectives, and or lived experience research
- Consider current/future nursing practice and research implications.
Case Study
Jessica Jones is an 18yo female who was previously diagnosed with Bulimia Nervosa. Jessica lives at home with mother, Marie. Her parents are divorced and her father lives in Western Australia. She has two older brothers both of whom live overseas, in the UK and USA respectively. Jessica decided to defer going to university for a year and currently works for a logistics company as a receptionist. Jessica was diagnosed with bulimia when she was 16years old. She was treated with cognitive behavioural therapy and made a good recovery. Over the last six months Marie, has noticed that Jessica has lost weight and there has been a change in Jessica’s behaviour including, being secretive around food, becoming more antisocial and withdrawn, eating alone and avoiding other people at meal times, and frequent trips to the bathroom after eating. Jessica was reviewed by the GP who referred her to the local hospital with hypokalaemia, hypernatraemia and cardiac arrhythmias. Vital signs: low blood pressure, irregular pulse, and feeling dizzy at times for unclear reasons. Jessica’s weight and height in ED: 170cm and 50kg. Admitted to the cardiac unit for cardiac monitoring and treatment of hypokalaemia (2.9mmol/L) and hypernatraemia, on background of binge eating, purging and laxative abuse. Jessica voiced feelings of regret, guilt, low mood, and shame. Jessica was reviewed by the Mental Health Team and SCOFF questionnaire performed. A plan of care was arranged that included potassium supplements and continuous cardiac monitoring, fluid balance chart, food chart and supervision at all meal times, bed rest with supervised toilet privileges before meals and 1 hours after meals. Jessica has voiced her anger at these rules and does not wish comply
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