NURS2001 Health of Adults 2026
Assignment 1: Nursing Case Study Report

Aim:

According to the Nursing and Midwifery Board of Australia’s (2016) Registered nurse standards for practice, nurses need to be able to;

• Think critically and analyse nursing practice (Standard 1),

• Comprehensively conduct assessments (Standard 4),

• Develop a plan for nursing practice (Standard 5),

• Provide safe, appropriate, and responsive quality nursing practice (Standard 6),

• Evaluate outcomes to inform nursing practice (Standard 7).

Thus, the aim of this assessment is to provide students with an opportunity to analyse and evaluate a clinical case scenario so that the development of critical thinking and reflection is promoted. In this assessment, students will be required to interpret clinical information and draw upon their knowledge of pathophysiology, the nursing process and evidence-based nursing practice, and articulate new learnings in the case study report.

What you need to do:

Based upon the clinical scenario provided below, construct a case study report. This includes a detailed report of the person’s clinical presentation, nursing management, 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 nursing 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 person, should underpin the identified nursing problems. In turn, evidence-based nursing care and interprofessional care that relate to the problems should be clearly discussed and must be relevant to the clinical scenario.

The case report must include the following:

Introduction - 200 words

Using the ISBAR clinical handover framework, introduce the person and provide a brief overview of their case. Provide an outline of the purpose and structure of the report. PRV14404 / CRICOS 04249J

Primary admission - 300 words

In this section provide a summary of the reasons why the person was admitted to hospital. For this, include a brief description of the pathophysiology of the person’s medical problems and their clinical manifestations. Support this discussion with contemporary, evidence-based literature.

Identify two (2) nursing problems – 300 words

Using the previous description of the pathophysiology and observed clinical manifestations, identify two (2) nursing problems that are to be prioritised for the person. Justify your selection and briefly describe why each is important in the person’s management. Support your discussion by utilising contemporary, evidence-based literature.

Tip: Importantly in this section, you should prioritise the care that is required for the person. Consider what is the most pressing concern for the person at this stage.

Nursing management - 1000 words – 500 words per problem

In this section, you will focus on the implementation of the nursing process to each of the identified problems from the section above. That is, for each identified problem you will need to include a discussion of;

• One (1) appropriate nursing assessment and its rationale,

• One (1) appropriate nursing intervention related to your assessment. Provide a rationale for each intervention,

• Nursing implications related to the medication management of the ongoing management of each problem.

Support your discussion by utilising contemporary, evidence-based literature.

Tip: This section of the report focuses on assessments and interventions that the Registered nurse (RN) conducts.

Remember to discuss what the RN physically does to provide optimal person-centred care as part of the nursing management plan.

Discharge planning - 500 words

The discharge plan must focus on the interdisciplinary management for this person and should refer to the nursing problems addressed throughout the report.

In this section, discuss the aim of discharge planning and the importance of using an interdisciplinary approach. Also, discuss the role of the RN in facilitating a multidisciplinary discharge plan for this person. Identify and justify the members of the multidisciplinary health care team and the role that they would play. For this, you should refer to the identified nursing problems discussed in the report.

Tip: Avoid reverting to simple referrals to other members of the health team.

Conclusion - 200 words

Summarise the major findings of this case report. The conclusion should not introduce new material that has not been previously addressed within the report.

Referencing

The content of the case report must be supported through referencing of current evidence-based literature and must include a reference list in APA 7 style and intext citations. Students will be assessed on referencing and academic writing.

Tip: Avoid using minimal sources or material used of poor quality e.g. reliance on secondary sources such as websites of organisations related to the subject matter. Ensure to integrate the literature into the discussions. Always check both intext referencing and the reference list to ensure they are correct, relevant, and complete.

Overall writing and presentation

As per academic writing requirements 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. You will be assessed on the overall writing and presentation – compliance with the academic writing guidelines will avoid loss of marks for this assessment.

Tip: Avoid using dot points, refer to previous assessments and reach out for academic support early

Clinical scenario

IDENTIFY:

Patient Name: Mr Robert Palmer

Age/Date of Birth: 10 November XXX – 51 years old.

Sex: Male

SITUATION:

Mr Palmer has presented to the emergency department (ED) after falling from a ladder from a height of 2m and hitting his head on the ground when he landed. He was cleaning his gutters to reduce fire risk and protect his home. As a result of the fall, he also sustained a large wound on his left leg and a graze on his right forearm.

BACKGROUND:

Mr Palmer’s past medical history includes:

* Type 2 diabetes mellitus,

* Hypercholesterolaemia,

* Hypertension (poorly controlled),

* Reformed smoker - 25 cigarettes a day, quit 5 years ago,

* Body Mass Index (BMI): 26,

* Controlled Atrial Fibrillation,

* Previous poor medication compliance.

Mr Palmer’s currently prescribed medications include:

* Metoprolol (50mg bd)

* Atorvastatin (80mg daily),

* Verapamil (40mg tds),

* Apixaban (5mg bd).

ASSESSMENT:

Upon admission, Mr. Palmer underwent a series of diagnostic tests, including a Computerised Tomography (CT) scan and Magnetic Resonance Imaging (MRI) of his head. Initial results from these radiological examinations determined no abnormalities in the brain. An x-ray of his left leg also demonstrated no bony abnormality, and only light bruising was obvious upon visual inspection of the leg. However, considerable swelling is noted in the lower left leg. The graze on his right forearm and wound on his left leg are dressed. An electrocardiogram (ECG) was also taken demonstrating controlled atrial fibrillation.

RECOMMENDATIONS:

Thus, it was recommended that:

* Mr Palmer is admitted to high dependency ward for monitoring.

* Administer oxygen therapy and titrate to maintain oxygen saturation > 95 %.

* Conduct routine blood analysis including; full blood examination, electrolytes and urea, coagulation studies, and high sensitivity troponin levels.

* Commence strict fluid balance chart.

* Conduct half hourly neurological assessments.

* Conduct hourly neurovascular assessment of left leg.

* Perform ECG.

* Position head up 30 deg.

* Mobilise as tolerated.

NURSING HANDOVER:

It is 24 hours post admission; you are about to start your early shift in the high dependency unit and Mr Palmer is your allocated patient. During the morning bedside handover, the night duty Registered nurse (RN) reports Mr Palmer,

* Had a restless night, slept for short periods only and at times was disorientated.

* Vital signs (last measured at 0600) include:

o Temperature: 37.6 deg

o Heart rate: 100 beats per minute and irregular.

o Respiratory rate: 24 breaths per minute.

o Blood Pressure 100/50 mmHg.

o Sp02 92 % on 2L via nasal specs.

Following nursing handover at 0700, you introduce yourself to Mr Palmer. Now you notice the following:

* He begins to complain of a sudden onset headache,

o you note that his breathing is laboured despite continued oxygen therapy as ordered,

o you also note that his speech becomes slurred,

o upon closer inspection you see that he is also pale and diaphoretic,

o lastly, he is complaining of nausea and photophobia.

Your Nursing Assessment Based on your initial interactions with Mr Palmer, you now decide to reassess his vital signs and document the following results at 0800:

* Temperature: 37.6o

* Heart rate: 48 beats per minute and irregular.

* Respiratory rate: 8 breaths per minute and irregular.

* Blood Pressure 190/50 mmHg (widened pulse pressure).

* Glasgow Coma Score (GCS) is 11 (E: 2, V: 4, M: 5).

* Sp02 92 % on 2L via nasal specs.

Tip: get an RDR chart and fill it out with all of Mr Palmers observation data.

Additional assistance to complete this assessment.

Referral to the topics delivered in this course will provide students with the knowledge required to promote successful completion of this assessment. For example, the weekly learning activities to develop a plan of care will prepare students to complete the case report. Students should make sure that they read and cite all information provided and use opportunities to discuss this assessment in the weekly tutorials or virtual classrooms.