Rationale
This assessment task is specifically designed to assist the development of your clinical
judgment, clinical reasoning, and decision-making skills. The development of these skills is
foundational to influencing positive impact on patient outcomes. Hence, in fluencing positive
outcomes for your patient is the context that the clinical scenario for this assessment task is
particularly focused and uses a problem-based learning framework to assess your learning
USQ TIME 10:41 am Mon, 1 Jun 2015
and development in the nursing profession.
Assessment task details
This written assessment piece is based on the following clinical scenario.
Case: Mr Larry Lyons
Mr Larry Lyons is admitted to the East Wing surgical ward of University Hospital and
scheduled for a cholecystectomy. It is intended that the procedure will be performed
by laparoscopy, however a laparotomy may be required. As part of his perioperative
care you are required to plan his nursing intervention for perioperative care (see Skill
36-1 in your Dempsey text).
On admission you documented his vital signs as follows:
Vital signs : T 37C, P 106, RR 22, BP 140/94, SpO 97%, Wt 60 kg, Ht 198cm
UA: + protein, + blood, ++ nitrites, pH 5
Pain score: 6/10
Mr Lyons states to you that although he is willing to have an operation that may
involve additional procedures, that is the laparotomy, he is unwilling and
fundamentally opposed to providing consent for a blood transfusion.
Your task is as follows:
Part 1: Documentations
1. Glosssary of terms “ define a minimum of 12 healthcare terminologies and abbreviations
pertaining to this case and those used in your documentations.
2. Case analysis: Using the FILA framework, analyse the clinical situation and plan your
nursing intervention (2 “ 4 pages).
3. Nursing documentation : Using the SOAP Framework, prepare your documentation for
Mr Lyon™s care.
4. Handover : Using the SBAR Framework, prepare your handover nursing notes.
Part 2: Essay
Clinical decision making and reasoning: This is a written assignment in essay format (1000-1200 words). Based on your