Patient Handover Report and Reflection - NUR286 Task 2 Assignment

This document presents a student's Task 2 assignment for the NUR286 course, focusing on patient handover and reflection. The assignment includes a detailed patient handover report using the ISBAR framework, covering identification, situation, background, assessment, and recommendations for a patient named John Williams. The report highlights the patient's medical history, current condition (including vital signs and pain levels), and prescribed medications. The student also provides recommendations for further care, such as monitoring vital signs and repeating a chest X-ray. Part 2 of the assignment requires a written reflection on the student's practice from Task 1, incorporating feedback and outlining learning goals. The assignment adheres to specific formatting guidelines, including word count, referencing, and the use of Australian spell check. The provided case studies and verbal handover tools (ISBAR) support the assignment's structure and content.

[Surname, first name, student number; scheduled lab time/day, tutor full name]
 Use this template for your task 2 written assignment
 Ensure you update the header with your own unique details
 Ensure you use Australian spell check
 Ensure you update your reference list, and this is always on a separate page at the end of
the document
 Use your verbal handover tool as a trigger to structure your handover, noting some
information may/may not be relevant; e.g. under identification stating the patients full
name and age is sufficient if the URN is unknown.
 Short succinct sentences would be appropriate in Part 1.
 Review the course FAQ’s that relate to Task 2 on Blackboard (under ‘Getting Started’ tab)
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[Surname, first name, student number; scheduled lab time/day, tutor full name]
Part 1
Identification
My name is (). I am the nurse currently caring for the patient by the name John
Williams. John William has already identified his next of kin, and he/she is aware of
the current situation regarding John Williams medical status. The relatives of John
Williams have not yet presented themselves to the medical facility. This handover
report was written to help the next nurse who will be assigned to the patient.
Situation
John Williams was admitted to the hospital with complains of difficulty in
breathing. Additionally, John Williams also complained of respiratory failure. John
Williams is very sick, and I suspect that he might be suffering from pleural effusion.
Moreover, I also suspect that John might be suffering from complications from an
intercoastal drainage tube that was inserted in his left side.
Background
John Williams is a retired police officer. John Williams was also hospitalized
six weeks ago after complaining of breathing problems. John started experiencing the
difficulties in breathing after a surgical procedure known as gastrectomy was performed
on him to treat stomach cancer. He is an alcoholic drinker but only drinks in moderate
quantities. In addition to drinking, John is also a smoker. Besides, John also
experiences bowel bladder habits on regular occasions. The bowel bladder habits may
be the reason John is experiencing pain. The bowel bladder habits may be caused from
the surgical procedure that was conducted on his stomach. Additionally, John Williams
also suffers from Chronic obstructive pulmonary disease.
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[Surname, first name, student number; scheduled lab time/day, tutor full name]
His medication chart includes prn Panadol to relieve the pain, multivitamin to
supplement his body with vitamins and minerals, and Salbutamol 5 mg NEB prn to
assist mitigating the difficulty in breathing. Additionally, John William has a
prescription of prn 5 mg Morphine SC to reduce his pain that was caused due to the
breathing problems. His pain level was 7/10. Furthermore, John was also prescribed
with 1 gram of amoxicillin to be taken every six hours to help cure or prevent any
bacterial infections. The bacterial infections may occur either due to the respiratory
failure or the operation that was performed in his stomach. In addition, John was also
administered with IVC flushes q4h accompanied by 5ml N\Saline 0.9% through
nebulization. There are no current alerts or allergy issues.
Assessment
John Williams is extremely distressed and uncomfortable. His current condition
is worse compared to the previous health status. His body temperature was recorded at
37.6°C, his heart rate was recorded at 78 beats per minute, and blood pressure monitor
at 162/90. Moreover, his oxygen saturation level was recorded at 96%. Additionally,
John’s respiratory rate was recorded at 24 breaths per minute, the level of pain during
respiration was 2-3 out of 10. He was admitted to the Integrated Comprehensive Care
for 30 minutes. According to the recorded information that was obtained after John was
observed for 1000 hours, his body temperature indicated that he might be having a
fever. Additionally, his heart rate was between 60 to 100 beats per minute, indicating
that it was normal. His blood pressure indicated that he was in stage 2 hypertension. His
oxygen saturation level was at 96%, which is good and therefore, no concern.
Furthermore, the level of pain during respiration was 2-3/10, indicating that he had no
severe pains. The pains are caused due to the fact that john Williams is experiencing
difficulties in breathing.
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[Surname, first name, student number; scheduled lab time/day, tutor full name]
Recommendations
I recommend that John Williams should be given a triflo/incentive spirometry for 4
hours and an ICC drain on suction –‘ve 15 cm on Atrium drain. Furthermore, the nurse
should also monitor his blood pressure and temperature to check if they have gone back
to normal or they are still consistent with my observation. Moreover, the nurse should
repeat the chest X-ray and remove the inferior vena cava filter. Lastly, the nurse should
change the dressing of the Integrated Comprehensive Care on a daily basis.
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[Surname, first name, student number; scheduled lab time/day, tutor full name]
Part 2
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[Surname, first name, student number; scheduled lab time/day, tutor full name]
Reference(s)
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