Date PRE POST PRE POSTna na  na na   .docx

Date PRE POST PRE POST
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*Notify surgeon/Reg n/a n/a n/a
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2400 n/a n/a
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(circle) Top/Bottom/Partial denture n/a n/a n/a n/a
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Pre-Operative Antibiotics: n/a n/a
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UR NUMBER 075486
Chelsea Bassett
Joelle Latham
Lisa Leanard

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Chelsea bassett
Joelle Latham
Lisa Leonard
Signature:
Signature:
Signature:
Post- Operative check performed by:
Xray/Scans:
Patient reception check performed by:
Given and signed
Given and signed
Pre-Operative check performed by:
Medical Certificate
Follow up Appointments
Observations Checked
Discharge SummaryGraduated compression stockings insitu
(Circle) N/A / with Patient / With Doctor
VTE Prevention Anticoagulant

Investigations: FBC updated
Check/Wound/Drain tube
POST OP ONLY
Epidural Test Dose
Post Op Orders
Glasses
Hearing aids
Posthetic devices
Pacemaker insitu:
Seen by technician
Pre Op Prep: Skin Prep (Betadine)
Bariatric: (>120kg) - Notify Theatre
(obtain Hover mat prior to transfer to OT)
Cytotoxic Drugs Within 48 hours
Weight Recorded:
Anaes. Record
Fasting time: Food
Fluid(Document time)

Own teeth:
Pre-medication Ordered
Ordered
IV Therapy IV bung flushed
IV orders written
Clip
Bowel Prep
Identification Labels: Min of 20
Infectious State: Please state:
Theatre notified
History: (circle) Old New
Jewellery: (circle) Taped / Removed
Make-up/Nail Polish: Removed
Underwear: (circle) Disposable / Own
Female Sanitary Products:
NB:Please remove tampons Pad in situ
Personal items with patient:
Contact lenses

Procedure on consent form corresponds with
Theatre List
* Do not allow pt to leave holding bay
Side and site of surgery:
Allergies:
Wrist band
Patient Identifcation (check against
Consent form:
Admission form: Wrist band
Leg band
Patient/rep signature
Doctors signature
Comments: (e.g. Alerts, manual handling issues, Infections,
Bariatric skin integ.)
PRE AND POST OPERATIVE CHECKLIST YES P NO O Not
Applicable N/A
5/03/2018

DOCTOR John Smith
DATE OF BIRTH
ROBERTS
Darren
25 Happy Street
CAIRNS 4860
23/11/1968
SURNAME
FIRST NAME
ADDRESS
SIMULATED HOSPITAL
Name ROBERTS, Darren Lab ID
UR 075486 Request Date 04/03/2018
Age/Sex 50 years, Male Reported Date 05/03/2018
Test Normal Range Result
Na+ mmol/L 139
K+ mmol/L 4.5

CL- mmol/L 100
Bicarb mmol/L 25
Urea mmol/L 3.5
Creatinine mmol/L 65
Glucose mmol/L 5
Ca++ mmol/L 2.5
Mg++ mmol/L 0.78
CRP mg/L 0.2
Serum Fe µmmol/L 20
Transferrin µmmol/L 45
21- 29
3.0 - 8.0
14 - 32
40 - 260
0 - 5
Laboratory Report
2100045678
Biochemistry Results
2.25 - 2.65

0.7 - 1.1
135 - 145
3.5 - 5.3
95 - 105
50 - 120
3.9 - 6.2
Simulated Hospital
UR 075486 Request Date 04/03/2018
Hb g/L 155
WCC x 10⁹L 4.3
Neutrophils x 10⁹L 2
Lymphocytes x 10⁹L 1.8
Platelets x 10⁹L 300
HCT % 48

INR ratio 2.8
APPT seconds 27
Fibrinogen mg/dL 300
2.0 - 3.0
23 - 28 seconds
Males: 160 - 450mg/dL
150 - 450
4.0 - 11.0
2.0 - 8.0
1.0 - 4.0
34 - 54%
Laboratory Report
2100045678
FBE
125 - 175M, 110 - 160 F
Simulated Hospital

UR 075486 Request Date 04/03/2018
Total Protein g/L 65
Albumin g/L 42
Globulin g/L 28
Total Bilirubin µmmol/L 9
ALP IU/L 50
ALT IU/L 40 - 50
60 - 80
38 - 55
20 - 32
2 - 20
30 - 120
Laboratory Report
2100045678
LFT
Simulated Hospital

RN: Lisa Leonard
Item Number (s)
YES
INFECTION STATUS
CLEAN
Dressings INFECTED
Drain Tubes POTENTIALLY INFECTED
DATE:
Operation Performed:
Post Operative Orders (Please print or write clearly)
- RPAO
- IV therapy as charted
Laprascopic +/- Open Cholecystectomy
Details of Operation (including incision, organs removed and
findings)
URN
SURNAME
GIVEN NAME

ADDRESS
DATE OF BIRTH
Reece Latham
5th March 2018
John Smith
Chronic Cholecystitis
75486
ROBERTS
Darren
25 Happy Street
CAIRNS 4860
23/11/1968
John SmithOPERATION REPORT
Simulated Hospital
DOCTOR
Date of Operation:
Surgeon:
Operative Diagnosis:

Assistant:
- Pain relief as charted
- Diet and fluids as tolerated once bowel sounds present
- Ambulate as tolerated
Speciman to Pathology
- Dressing to remain intact for 7 days
- Follow up with local GP if any concerns post discharge
SURGEONS SIGNATURE John Smith
Original Copy to remain with Hospital Duplicate Copy for
Surgeons records
REASON
Steri Strips and Gauze
Drug and I.V Therapy - As charted arts
5th March 2018
P
Patient placed on standard operating table in supine surgical
position and sites of compression well
padded. Patient prepared with iodine solution and draped in a
sterile fashion. A paramedian incison
was made approximately 5cm in lenght wiht a #10 blade
scalpel, Next haemostasis was obtained
using electro Bovie cautery. Dissection was carried down

transrectus in the midline to the posterior
rectus fascia, which was grasped and the abdomen was entered.
The gallbladder was immediately
visualised and brought into view. It was found to be inflammed,
thickened and filmy adhesions were
present. Adhesions to the gallbladder taken down with sharp
dissection. Contents of gallbladder
were aspirated. Gallbladder disected free from liver bed, placed
into specimen bag and
The peritoneum as well as posterior rectus fascia was
approximated with a running #0 Vicryl
suture and tehn the anterior rectus fascia was clised in
interrupted figure- of-eight #0 Vicryl sutures.
Skin staples were used on the skin and sterile dressings were
applied. The patient was transferred
to recovery in a stable condition.
- VTE precautions as charted
withdrawn through the incision. Prior to closure, peritoneal
cavity examined and showed complete
signs of haemostasis, no bleeding from the gallbladder bed and
no evidence of bowel injury.
Original Copy to remain with Hospital Duplicate Copy for
Surgeons records
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�LATROBE
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Simulated Hospital
FLUID BALANCE CHART
PLEASE NOTE
• Urine output <50mls / 4hrs requires MET to be called
• Urine catheters must be measure and recorded minimum 4/24
• All fluid volumes are to be checked, totalled and balanced
minimum 8/24
• Fluid Balance Summary MR 128 to be completed at 2400 hrs
• This chart is to be filed in the medical record
DATE INPUT (mis) HOUR PROG.
INTRAVENOUS/EPIDURAUSUBCUTANEOUS
GASTROINTESTINAL
TOTAL TOTAL
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TYPE/DESCRIPTION VOL TIME
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24 hr 24 hr
total total
URN
SURNAME

GIVEN NAMES
ADDRESS
DATE OF BIRTH
SEX
DOCTOR
OUTPUT (mis)
COMMENTS
75486
ROBERTS
Darren
25 Happy Street
CAIRNS 4860
23/11/1968
Male
John Smith
HOUR PROG.
TOTAL TOTAL
PROG.
BALANCE

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Darren Roberts Documentation
Enquiry One - Darren Roberts
Darren Roberts, 50 years admitted for Elective +/- Open
Cholecystectomy
Darren's Story
Darren lives in Cairns where he is the owner/operator of a
diving boat tour company. He has moved to a more sedentary
role over the last few years and misses getting out and working
with the tourists.
Darren has one son, Jake, 15 who lives in Wallan, Victoria with
his mum Lisa, step dad Kevin and his 5-year-old stepsister

Ruby.
Jake and Darren have a good relationship, Jake fly’s to Cairns
twice a year during school holidays to stay with his Dad.
Darren’s History
DOB: 23/11/1968
Address: 25 Happy Street Cairns
Smoker: 30 per day for last 20 years
Social Drinker 2 heavy beers a day after work and up to 10 a
day on the weekends - Darren’s favourite saying -It’s 5 o’clock
somewhere’
^BMI -33 H: 1.8m W: 110Kg Waist: 115cm
Darren has a past medical history including, hypertension,
hyperlipidemia, mild depression and GORD. He currently takes
medication for these conditions.
· Hypertension
· Hyperlipidemia
· Mild Depression
· Gastric Oesophageal Reflux
He has experienced two episodes of upper abdominal pain
during the night with associated nausea and vomiting within the
last month.
Medications
Generic name
Trade name
Dose
Atorvastatin
Lipitor
10mg Daily
Atenolol
Noten
50mg Daily
Sertraline
Zoloft
20mg BD

Ranitidine
Zantac
150mg daily
Darren does not attend regular check-ups with his GP. He last
had his medicaitons reviewed when he presented to the GP
around 12 months ago with his first presentation of upper
abdominal pain, nausea and vomiting. He was commenced on
Ranitidine at tis time.
In the last month, Darren has had two more severe episodes of
upper abdominal pain with nausea & vomiting. He ignored the
first episode and it settled after 24 hours. However, Darren has
presented to the Emergency Department in Cairns 1/7 ago with
similar symptoms but more severe.
Darren’s diagnosis is mild- severe Cholecystitis. Darren has
been transferred to the surgical ward where he is awaiting an
elective Laparoscopic +/- Open Cholecystectomy. Darren has
had pre- operative blood pathology collected including his
Cholesterol, which is reading high. This is part of Darren’s pre-
operative work up.
Darren Roberts Documentation
Enquiry One - Darren Roberts
Darren Roberts, 50 years admitted for Elective +/- Open
Cholecystectomy
Darren's Story
Darren lives in Cairns where he is the owner/operator of a
diving boat tour company.
He has moved to a more sedentary role over the last few years
and misses getting
out and working with the tourists.

Darren has one son, Jake, 15 who lives in Wallan, Victoria with
his mum Lisa, step dad
Kevin and his 5-year-old stepsister Ruby.
Jake and Darren have a good relationship, Jake fly’s to Cairns
twice a year during school
holidays to stay with his Dad.
Darren’s History
DOB: 23/11/1968
Address: 25 Happy Street Cairns
Smoker: 30 per day for last 20 years
Social Drinker 2 heavy beers a day after work and up to 10 a
day on the weekends - Darren’s favourite saying -It’s 5 o’clock
somewhere’
^BMI -33 H: 1.8m W: 110Kg Waist: 115cm
Darren has a past medical history including, hypertension,
hyperlipidemia,
mild depression and GORD. He currently takes medication for
these conditions.
Hypertension
Hyperlipidemia
Mild Depression
Gastric Oesophageal Reflux
He has experienced two episodes of upper abdominal pain
during the night
with associated nausea and vomiting within the last month.
Medications
Generic name

Trade name
Dose
Atorvastatin
Lipitor
10mg Daily
Atenolol
Noten
50mg Daily
Sertraline
Zoloft
20mg BD
Ranitidine
Zantac
150mg daily
Darren does not attend regular check-ups with his GP. He last
had his medicaitons
reviewed when he presented to the GP around 12 months ago
with his first presentation
of upper abdominal pain, nausea and vomiting. He was
commenced on Ranitidine at this time.
In the last month, Darren has had two more severe episodes of
upper abdominal pain with
nausea & vomiting. He ignored the first episode and it settled
after 24 hours. However, Darren
has presented to the Emergency Department in Cairns 1/7 ago
with similar symptoms but
more severe.
Darren’s diagnosis is mild- severe Cholecystitis. Darren has
been transferred to the surgical
ward where he is awaiting an elective Laparoscopic +/- Open
Cholecystectomy. Darren has
had pre- operative blood pathology collected including his
Cholesterol, which is reading high.
This is part of Darren’s pre-operative work up.

Enquiry Based Learning
This enquiry will introduce the students to the concepts of
managing a patient requiring hospitalisation
and a surgical intervention. It will also explore communication
skills, legal considerations, psychosocial
care and the impact of hospitalization upon the family unit.
This enquiry will require students to use the clinical reasoning
cycle and health assessment skills to plan
pre and post-operative care for Darren.
It is important that you have a good understanding of the
concepts in Darren's story.
If you are unsure of any of the conditions or medicaitons, you
will need to explore these prior to attending your first
workshop.
l
ALCOHOL WITHDRAWAL
ASSESSMENT SCORING TOOL
(CIWA-Ar Scale)
Surname ________________________________
Given Name _____________________________
UR No _____________ DOB ________________

Address _________________________________
GP ________________ Sex _________________
Assess and rate each of the following : Refer to reverse for
detailed instruction in use of the CIWA-Ar-Scale
Nause a/vomiting (0 - 7)
0 - no ne; 1 - mild na us e a , no vo miting; 4 - inte rmitte nt
na us e a; 7 - c o ns ta nt na use a , f re quent dry he a ve s &
vo miting
Tr e mors (0— 7)
0 - no tremor; 1 - not visible but can be felt; 4 - moderate w/
arms extended; 7 - severe, even w/arms not extended
Anxie ty (0 - 7)
0 - no ne a t e as e; 1 - mildly a nxio us; 4 - mo de ra te ly
a nxio us o r gua rde d; 7 - e quiva le nt to a c ute pa nic s ta
te
Ag itation (0 - 7)
0 - normal activity; 1 - somewhat normal activity; 4 -
moderately
fidget/restless; 7 - paces or constantly thrashes about
Par oxy smal swe ats (0 - 7)
0 - no s we a ts; 1 - ba re ly pe rc e ptible s we a ting, pa lms
mo is t; 4 - be a ds o f wea rs o bvio us o n f o re he a d; 7 -
dre nc hing s we a t
O r ie ntation (0 - 4)
0 - oriented; 1 - uncertain about date; 2 - disoriented to date by
no more than two days; 3 - disoriented to date by > two days; 4
-
disoriented to place and / or person

Tactile Distur bance s (0 - 7)
0 - none; 1 - very mid itch, P&N, numbness; 2 - mild itch, P&N,
burning, numbness; 3 - moderate itch, P&N, burning, numbness;
4 - moderate hallucinations; 6 - extremely serve hallucinations ;
7
- continuous hallucinations
Auditor y Distur bances (0 — 7)
0 - not present; 1 - very mild harshness/ ability to startle; 2 -
mild
harshness, ability to startle; 3 - moderate harshness, ability to
startle; 4 - moderate hallucinations; 5 - serve hallucinations; 6 -
extremely severe hallucinations; 7 - continuous hallucinations
Visual Distur bance s (0 - 7)
0 - not present; 1 - very mild sensitivity; 2 -mild sensitivity; 3 -
moderate sensitivity; 4moderate hallucinations; 5 - severe hallu-
cinations; 6 - extremely severe hallucinations; 7 - continuous
hallucinations
He adache (0 - 7)
0 - not present; 1 - very mild; 2 - mild; 3 - moderate; 4 - moder-
ately severe; 5 - severe; 6 - very severe; 7 - extremely severe
Total CIWA-Ar score:
P R N Med : ( ci rc le one) Dose given (mg):
Diazepam Lorazepam Route:
Time of PRN medication administration:
Assessment of response (CIWA-Ar-score 30-60
minutes after medication administered )
RN Initials

Assessment Protocol:
a. Vitals Assessment Now.
b. If initial score ≥ 8 repeat q 1 h × 8 hrs, then if
stable q2h × 8 hrs, then if stable q4h.
c. If initial score < 8 for 72 hrs, d/c assessment. If
score ≥ 8 at any time, go to (b) above.
d. If indicated, (see indications below) administer
prn medication as ordered and record on MAR
and below.
Date
Time
Pulse
RR
O2 Sat
BP
Scale f or Scor ing:
Total Sc or e =
0 - 9: absen t or min imal wi thdr awal
10 - 19: mild to mode r ate wi thd rawal
Mo re than 20: se ver e withd rawal
Indica tio ns for PRN medica tio ns:
a. Total CIWA -AR sco re 8 or h igher if ord ered PRN o nly
(Symptom -tr iggered

method)
b. Total CIWS -Ar sco re 15 or highe r if on Sc hedu led
medica ti on (Sch edul ed +
prn method)
Conside r tran sfe r to ICU for any of the fo llow ing: Tota l s
cor e ab o ve 35, q1h
assess, x more tha n 8he s r equi re d, more than 4 mg/hr lor
aze pam × 3hr or 20
mg/hr diaze pam ×3hr req ui red, or r esp. dis tr ess
Roberts
Darren
075486 23/11/1968
25 Happy St, Carins
J. Smith M
5/3/
18
0300
90R
20
96%RA
140/
88
1
0

1
0
0
0
0
0
0
1
3
N/A
N/A
N/A
N/A
DS
Example: Diazepam withdrawal regime (Mild Dependence)
6am 12 midday 6pm 12 midnight
Day 1 10mg 10mg 10mg 10mg

Day 5 5mg - - 5mg
Day 6 5mg - - 5mg
Alcohol Withdrawal Assessment Scoring Guidelines (CIWA -
AR)
Na usea / vomiting - R a te o n sca le 0- 7
0 - No ne
1 - M ild na use a with no vo miting
2 -
3 -
4 - I nte rmitte nt na us ea
5 -
6 -
7 - C o ns ta nt na us ea a nd f re que nt dry he a ve s a nd vo
miting
Tremors - have patient extend arms & spread fingers. Rate on
scale 0
-7

0 - No tremor
1 - Not vis ible, but can be felt fingertip to fingertip
2 -
3 -
4 - Moderate, with patient’s arm extended
5 -
6 -
7 - severe, even w/ arms not extended
Anx iety - R a te o n s ca le 0 - 7
0 - No a nxie ty, pa tie nt a t e as e
1 - M ildly a nxio us
2 -
3 -
4 - Mo de ra te ly a nxio us o r gua rde d, so a nxie ty is inf e
rre d
5 -
6 -
7 - e quiva le nt to a c ute pa nic s ta te s se e n in s e ve re

de lirium o r a c ute sc hiz o phre nic re ac tio ns
Ag ita tion - R a te o n s ca le 0 - 7
0 - No rma l a c tivity
1 - So me wha t no rma l a c tivity
2 -
3 -
4 - Mo de ra te ly f idge ty a nd res tle ss
5 -
6 -
7 - P ac es bac k a nd fo rth, o r c o ns ta ntly thra s he s a bo
ut
Tactile disturbances - Ask, “Have you experienced any itching,
pins
& needles sensation, burning or numbness, or a feeling bugs
crawling
on or under your skin?”
0 - None
1 - Very mild itching, pins & needles, burning, or numbness
2 - Mild itching, pins & needles, burning, or numbness
3 - Moderate itching, pins & needles, burning, or numbness

4 - Moderate hallucinations
5 - Severe hallucinations
6 - Extremely severe hallucinations
7 - Continuous hallucinations
P a r ox ysma l Swea ts - Ra te o n sc a le 0 - 7
0 - No s we a ts
1 - Ba re ly pe rc e ptible s wea ting, pa lms mo is t
2 -
3 -
4 - Be a ds o f s wea t o bvio us o n f o re hea d
5 -
6 -
7 - D re nc hing s we a ts
Or ienta tion a nd clouding of sensor ium - As k “W ha t da y
is this ?
W he re a re yo u? W ho a m I ” R a te sc a le 0 - 4
0 - Orie nte d
1 - C a nno t do se ria l a dditio ns o r is unc e rta in a bo ut
da te

2 - D is o rie nte d to da te by no m or e tha n 2 ca le n da r
d a ys
3 - D is o rie nte d to da te by mo r e th a n 2 ca le nd a r d a
ys ?
4 - D is o rie nte d to pla ce a nd / o r pe rso n
Auditory disturbances - Ask, “Are you more aware of sounds
around
you? Are they hars h? Do they startle you? Do you hear
anything that
disturbs you that you know isn’t there?”
0 - Not present
1 - Very mild harshness or ability to startle
2 - Mild harshness or ability to startle
3 - Moderate harshness or ability to startle
Visual disturbances - Ask, “Does the light appear to be too
bright? It

its colour different than normal? Does it hurt your eyes? Are
you
seeing anything that disturbs you or that you know isn’t there?”
0 - No present
1 - Very mild sens itivity
2 - Mild sensitivity
3 - Moderate sensitivity
Headache - Ask, “Does your head feel different than usual?
Does it
feel like there is a band around your head?” So not rate
dizziness or
lightheadedness.
0 - No present
1 - Very mild sens itivity
2 - Mild sensitivity
3 - Moderate sensitivity

P ro ce dure :
1. A ss es s a nd ra te ea c h o f the 10 c rite ria of the CI
WA s ca le. Eac h c rite rio n is ra te d o n a sc a le fo rm 0 to
7, e xpec t fo r “Orie nt a tio n a nd c lo uding o f
s e nso rium” whic h is ra te d o n a s ca le f ro m 0 to 4. A
dd up the s co re d fo r a ll te n c rite ria / This is the to ta l
CI WA - Ar s co re fo r th e pa tie nt a t the
time . P ro phylac tic me dic a tio n, s ho uld be s ta rte d fo r
a ny pa tie nt with a to ta l C IW A -A r sc o re of 8 o r grea te
r ( ie . S ta rt o n withdr a wa l me dic a-
tio n) . If s ta rte d o n s c he dule d me dicatio n s ho uld be
give n fo r a to ta l C IW A - A r s co re of 15 o r gre a te r
2. D oc ume nt vita ls a nd CI WA - A r a ss es sme nt o n the
W ithdra wa l As s ess me nt S he e t. Do c ume nt a dminis tra
tio n o f PR N me dic a tio ns o n the as s es s-
me nt s he e t as we ll.
3. The C I WA-A r Sc a le is the mos t se ns itive to o l fo r
as se ss me nt of the pa tie nt e xpe rie nc ing a lc o ho l
withdra wa l. Nurs ing a ss es s me nt i s vita lly
impo rta nt. Ea rly inte rve ntio n f o r C IWA - A r sco re o f
8 o r grea te r pro vides the be s t mea ns to pre ve nt the pro
gres sio n of withdra wa l .
Patient Name: ______________________________________

UR Number: _________________ Darren Roberts 075486
URN O75486
SURNAME Roberts
GIVEN NAME Darren
ADDRESS 25 Happy St
Cairns
DATE OF BIRTH 23/11/1968
DOCTOR Smith
4/03/2018
2230
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PROGRESS NOTES
Including Initial History and Examination
NURSING: O/A: Presented to ED with an acute episode and
recent Hx of upper epigastric pain. P’t
report pain 7/10 radiating across upper abdomen,and has a
positive Murphy's sign. -------------------------
CNS: Pt. is alert and orientated to person place and time, GCS -
15, PEARLA. Morphine 5mg administered
via 18g IVC inserted in L)hand. NVS: CWMS present in all
peripheries, Capillary refill <3sec, and Pedal pulses
present. CVS: HR 99bpm/reg, BP, 155/88, Temp - 37.6, Nil
Chest pain, Base line ECG attended. Resp: RR
26rpm, minimal increase in WOB, pt. able to speak in full
sentences, nil cough or sputum, O2Sats 95% RA,
air entry Equal/Bilateral on auscultation, nil adventitious breath
sounds, GIT: History of N&V for last few
days, nil since admission, Bowel sounds present in all 4
quadrants, Bowels regular and patient continent of
bowels and urine, BGL 3.5mmol, increase pain on gentle

palpation consistent with positive Murphy's sign.
Integ: Braden Score - 18, skin intact, slightly warm and moist.
ADLS: Pt. normally attends to all ADLS
independently. Safety: provided with call bell and explained
how and when to use it, Social: No NOK
present, pt.s son lives in Melbourne -pt. is worried about him,
Pt owns his own company and is also
concerned about how this will run without him on site. Declined
pastoral care. MSE: Pt. is anxious regarding
needing to be admitted to hospital
....................................................................................Sally
Grimm RND1
Medical 0300: Bloods, Ultrasound and CT Scan R/V'd by
surgical team and diagnosis of Acute Cholecystitis.
Consent gained by patient for a Cholecystectomy +/- Open
procedure. Patient prepared for transfer to
surgical ward when bed is available. Plan: Theatre at 0800 in
the morning. Anaesthetist will see p’t in the
AM
...............................................................................................
............................................GBrigs RMO
Medical 0315: Documentation from emergency admission is
incomplete, this will be sent to the ward
ASAP
...............................................................................................
..........................................G Brigs RMO
Nursing: Darren transferred to surgical ward @ 0400 hours from
ED. CNS: GCS 15, alert & oriented, Pain
2/10 at rest, 3/10 on movement, CVS: HR90 reg, BP 110/85,
T37.8, nil chest pain, IVC insitu in L) hand,
VTE assessment completed, TED stockings insitu Resp: RR 20,
nil increase in WOB, able to speak in full
sentences, O2Sats 96%RA, GIT: nil N&V, Fasting for procedure
in the morning, Safety: Pt, oriented to ward,
provided with call bell and instructed when and how to use it.
Social: AWS assessment attended, made

arrangements for Darren to contact his son and business in the
morning prior to surgery...... Di Symes
RND1.....................................................................................
............................................................................
Nursing:Darren seen by anaethetist at 0700hrs, Consent signed,
Ed documentation has arrived and is in
patients file, Pre-operative checklist completed. Awaiting
tansfer to theatre.............Rachel Mckenzie RND1
Nursing:Patient transferred to theatre @
0740hrs.......................................................Rachel Mckenzie
RND1
5/3/18
0300
5/3/18
0315
5/3/18
0400
5/3/18, 0715hrs
5/3/18, 0740hrs
UR NUMBER UR NUMBER
SURNAME SURNAME
FIRST NAME FIRST NAME
ADDRESS ADDRESS
DATE OF BIRTH DATE OF BIRTH

DOCTOR DOCTOR
COMPLEX DISCHARGE SCREEN Discharge date &
destination
Diagnosis:
(medical, surgical, mental health):
GEM o
CNS (nerves, brain), CVS, Resp, GIT, urinary, skin)
DISCHARGE CHECKLIST if no what action was taken or N/A
Valuables Checklist complete P (Check ED Checklist for
Valuables)
Collection of Discharge Medications P Hospital Pharmacy P
Own Medications returned P PREDICTED DISCHARGE
Medical Certificate P Predicted date of discarge: Predicted
destination:
Pre-admission or new services notified P Name: Transport Self
P Family/Carer Taxi Ambulance Other
IV/subcutaneous cannula removed P PRE-ADMISSION
Dressing attended P eg HARP, HNSS, MOW, Home Help, PCA,

Case Manager (include details & notify Case Manager Liason)
Post d/c action plan (e.g COPD, asthma) Oxygen ordered
Medical discharge summary complete and P
copy to patient P
Family/Carer notified of discharge P
Check Oxygen & Suction, change if required P
Completed Medication Chart
Medications arranged with Pharmacy 1. ADMISSION HISTORY
Residential in Reach notified of discharge Is this a re -
Transfer letter completed (medical) How many times has patient
been in anyhospital in past 12 months? Nil
Facility notified of discharge time 2. ORIENTATION TO UNIT
Welcome information given and explained P Patients rights &
responsibilities booklist P
Inter-hospital transfer form completed P Telephone location P
Introduction to other patients P Bathroom location
At discharge checked by Nurse: Date: P TV P Discharge time
(10am) explained P Use of Nurse Call
VALUABLES No valuables with patients P 3. SOCIAL /
LIFESTYLE NO YES

Aboriginal/Torres Strait Islander P Aboriginal Liaison Services
Hearing Aids P Linguistically Diverse? P
Dentures P Does patient have a case manager? P Notify of
admission, Case Management
Jewellery P Does patient have a support person/carer? P Notify
W
Electrical items P Does patient live alone? P Social Worker (if
Mobile Phone P If no, who with (other than carer)? Name: P
Money and Credit Cards P if yes have arrangements been made?
P
Medications P Does patient drink alcohol daily? P Doctor if
Other Items Does patient smoke? P Complete Smoking
assessment
Completion of Screen by Nurse & Patient / Significant Other
nicotine dependence scale (MR92Q)

I am aware that any jewellery or valuables kept on me or in the
ward area, are my responsibility and I understand that Latrobe
Does patient use recreational drugs? P Doctor if possible issues
Simulated Hospital are not accountable for any loss or damage.
I understand that my care plan will be developed from the
Nurse & Patient or significant other must sign. If unable to
sign, state a reason why: Will current home arrangements be an
4. ADVANCE CARE PLANNING NO
Patient Name: Date: Does the patient have an Advance Care
Plan? P
Nurse Name: Date: Enduring Power of Attony (medical
treatment)? P
Enduring Power of Guardianship? P
ROBERTS
Darren
25 Happy Street
CAIRNS 4860
23/11/1968
John Smith

if P to any, activate Complex
Discharge Process
Patients returning to Residential Aged Care Facilities also
include the following
Patients transferred to another Health Service also include the
following
Hypertension, Atherosclerosis
Cooperative, compliant and communicating appropriately, No
signs of rashes, skin tears or lesions, chest
Clear on ausculation.
date & sign
Consider complex discharge planning
Referrals/action (P)
Provider details include: Admission notification Discharge
notification
service provided date & sign
07/03/2018 Relatives
04/03/2018
Cholecystitis
Chelsea Bassett
Darren Roberts

Chelsea Bassett
04/03/2018
04/03/2018
GENERIC ADULT PATIENT ADMISSION &
DISCHARGE SCREEN
Referrals/action (P)YES
Home DD Cupboard Drug Room
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Describe Items
(Do not tick here, Description must be provided)
Returned
Darren Roberts

N/A
N/A
075486 075486
ROBERTS
Darren
25 Happy Street
CAIRNS 4860
23/11/1968
John Smith
Clinicial file
A copy of these orders must be place in the
24 hours if possible
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
(Date & Sign)Home Patient Safe

Please Tick Location
N/A
SIMULATED HOSPITAL SIMULATED HOSPITAL
UR NUMBER UR NUMBER
SURNAME SURNAME
FIRST NAME FIRST NAME
ADDRESS ADDRESS
DATE OF BIRTH DATE OF BIRTH
DOCTOR DOCTOR
5. INFECTION CONTROL 13. DEPRESSION
MRSA/VRE Clostridium difficille/Other MRO P Swabs as per
Other Infection/Infectious disease P Infection co
6. MEDICATIONS
Does the patient have any allergies? P 14. ACTIVITIES OF
DAILY LIVING

Is patient taking more than 5 medications? P Medication Chart
Does patient use a dosette or webster pack? P If yes, Pharmacy
Does patient understand current medications? P Name of local
Pharmacy:
Is the patient likely to receive blood products this P Details of
any Tra
admission?
Has the patient ever had ablood product P
transfusion?
If yest to the above, has the patient ever had a If Yes, noted on
15. ELIMINATION
9
Is the patient disorientated? P

AMTS Score:
10. PAIN /
Does patient experience pain or discomfort? P Pain Service
Describe location, severity & life interference on care plan Date
of next replacement
11. SKIN INTEGRITY
On adm
MOBILITY/FALLS
Braden Screen completed? P Score Occu
If Braden score is ≤ 12 a Comprehensive skin assessment must
12. NUTRITION
Does the patient have any food allergies? P

MALNUTRTION SCREENING TOOL
Has the patient los weight No 0 P
recently with out trying? U
require the following items? If needed do they have Do items
need to be Complete MR 118
Yes, 1 - 5kg 1 if 2 or more, refer to dietitian and them? brought
Yes, over 5kg 2 comemnce upon HEHP Diet Yes No Yes No
Family and friends asked Falls prevention
required items in booklet
Non slip footear Date discussed provided
Mobility Aids
ROBERTS
Darren
25 Happy Street
CAIRNS 4860

23/11/1968
John Smith
ROBERTS
Darren
25 Happy Street
P
P
P
If concerns exist regarding safety with mobility or
function, refer to:
Complete Falls Prevention Screen, Assessment &
Strategies (MR118) if patient ≥ 65 years or Falls risk is
identified on ALERT SHEET or Yes to 2 or more of the
mobility & falls questions
P
P
P
P
P
P

Is the patient in need of frequent toileting?
NO YES
is the patient bariatric?
Has the patient had unexpected falls within the last 6
months
Does the patient have an unsteady/unsafe gait?
Is the patient agitated/confused/disorientated? (see
section 9)
Does visual impairment impact on everday function such
that the patient is considered unsafe?
P
P
P
P
P
P
I

Have incontinence of urine or faeces? (circle)
Use continence aids? What type?
Suffer from constipation or diarrhoea?
(circle and describe strategies)
Have a Urostomy/Colostomy (circle)
Does the patient have an indwelling catheter or an
intermittent catheter?
Grooming I I Mobility
NO YES Referrals/action (P)
Does the patient have frequency, buring or pain on
voiding?
Showering/Bathing I I Toileting I I
I
Level of Function Pre Morbid Level of Function Pre Morbid
Current
Dressing I I Eating
Current
I

SCORE Referrals/action (P)
18
P
NO
if the patient is aged 65 years or older, or P in the yes column
complete Multidisciplinary delirium & cognition scfreen and
stickers
Recent mood or energy level changes?
Recent changes in sleep patterns, significant
Yes to weight loss/decrease in section 12
Key: I = Independent S = Supervision A = Able to assist D =

Dependent
I
Referrals/action (P)YES
CAIRNS 4860
23/11/1968
John Smith
N/A
P
P
P
N/A
N/A
075486 075486
N/A
SIMULATED HOSPITAL
SIMULATED HOSPITAL
Process Description Darren

Describe of list facts. Context, objects
or people
This is where we begin Data Collection
Darren is a (50) year old male who is scheduled for an Open
Cholecystecomy.
What else do we know about Darren -context, people and
situation?
Review Current inforamtion (e.g.)
handover reports, patient history,
patient charts, results of
investigations, and nursing/medical
assessments previously undertaken.
Gather new information (e.g.
undertake patient assessment)
Admission obs And pre op assessment
Subjective & Objective: Vitals:
Respiratory Ax:
CVS Ax:
Abdo Ax:
Pathology:

Recall knowledge (e.g.
pathophysiology, phsyiology,
pharmacology, epidemiology,
therapuetics, culture, contexct of
care, ethics, law)
Consider pathophysiology of upcoming surgery -what is a
cholecystectomy? What is
the difference between a Laproscopic procedure and an Open
procudere? How will
this impact Darrens recovery? Why?
Consider Darrens history -
what impact will this have on his anaesthetic
risk/recovery/post-operative
complications? What are the issues around
Legal -consent etc
Interpret: analyse data to come to an
understanding of signs or symptoms.
Compare normal vs abnormal
Discriminate: distinguish relevant
from irrelevant information;

recognise inconsistencies, narrow
down the information to what is most
important and recognise gaps in ccues
collected.
This is where we begin to Cluster the data, to make sense of it
in this patient context.
Relate: discover new relationships or
patterns; cluster cues together to
identify relationships between them.
Infer: make dedcutions or form
opinions that follow logically by
interpreting subjective and objective
cues; sconsider alternatives and
consequences.
Match: current situation to past
situations or current patient to past
patients [usually an expert thought
process]
Predict: an outcome [usually an

expert thought process]
Synthesis: facts and inferences to
make a definitive diagnosis of the
patients problem.
Nursing Daignosis - Can be Auctal or Potential.
The Problem realted to the Aetiology (cause) as evidenced by
the signs & symptoms.
Describe what you want to happen, a
desired outcome and a time frame
Goal for solving the patients problem. Can be short term or
long term -
Needs to be SMART
Select a course of action between the
different alternatives available
These are your Nursing Interventions -how you are going to
achieve the Goal and Solve
the problem.
Evaluate the effectiveness of
ourcomes and actions. Ask: Has the

situation improved now?
How has the situation improved and How do we know it has
improved. i.e. -
Evaluations need to be measureable (Vital signs, Pain Score
etc.)
Contemplate what you have learnt
from this process and what you cuold
have done differently.
Reflection
Process Description Darren
Describe of list facts. Context, objects
or people
This is where we begin Data Collection
Darren is a (50) year old male who is scheduled for an Open
Cholecystecomy.
What else do we know about Darren -context, people and
situation?
Review Current inforamtion (e.g.)

handover reports, patient history,
patient charts, results of
investigations, and nursing/medical
assessments previously undertaken.
Gather new information (e.g.
undertake patient assessment)
Admission obs And pre op assessment
Subjective & Objective: Vitals:
Respiratory Ax:
CVS Ax:
Abdo Ax:
Pathology:
Recall knowledge (e.g.
pathophysiology, phsyiology,
pharmacology, epidemiology,
therapuetics, culture, contexct of
care, ethics, law)
Consider pathophysiology of upcoming surgery -what is a
cholecystectomy? What is
the difference between a Laproscopic procedure and an Open

procudere? How will
this impact Darrens recovery? Why?
Consider Darrens history -
what impact will this have on his anaesthetic
risk/recovery/post-operative
complications? What are the issues around
Legal -consent etc
Interpret: analyse data to come to an
understanding of signs or symptoms.
Compare normal vs abnormal
Discriminate: distinguish relevant
from irrelevant information;
recognise inconsistencies, narrow
down the information to what is most
important and recognise gaps in ccues
collected.
This is where we begin to Cluster the data, to make sense of it
in this patient context.
Relate: discover new relationships or
patterns; cluster cues together to

identify relationships between them.
Infer: make dedcutions or form
opinions that follow logically by
interpreting subjective and objective
cues; sconsider alternatives and
consequences.
Match: current situation to past
situations or current patient to past
patients [usually an expert thought
process]
Predict: an outcome [usually an
expert thought process]
Synthesis: facts and inferences to
make a definitive diagnosis of the
patients problem.
Nursing Daignosis - Can be Auctal or Potential.
The Problem realted to the Aetiology (cause) as evidenced by
the signs & symptoms.
Describe what you want to happen, a

desired outcome and a time frame
Goal for solving the patients problem. Can be short term or
long term -
Needs to be SMART
Select a course of action between the
different alternatives available
These are your Nursing Interventions -how you are going to
achieve the Goal and Solve
the problem.
Evaluate the effectiveness of
ourcomes and actions. Ask: Has the
situation improved now?
How has the situation improved and How do we know it has
improved. i.e. -
Evaluations need to be measureable (Vital signs, Pain Score
etc.)
Contemplate what you have learnt
from this process and what you cuold
have done differently.
Reflection

ASSESSMENT Guidlelines
Assessment 1. Clinical Case Study (1,500 words) 40%
Relevant SILOs:
1. Apply the Australian Nursing and Midwifery Board [ANMB]
Standards of Practice for a Registered Nurse when caring for
individuals and their families,with Cardiovascular, Respiratory
and Endocrine disorders
2. Describe the impact of hospitalisation on individuals and
their families.
3. Provide person-centred care, using the Clinical Reasoning
Cycle to individuals experiencing Cardiovascular, Respiratory
and Endocrine disorders.
Rationale:
The purpose of this assessment task is to assess the student
nurses ability to think critically and apply the clinical reasoning
cycle to plan patient care.
As a Registered Nurse, you will be required to make judgments
and prioritise your patients care multiple times per shift. This
assessment task is designed to develop the sophisticated
thinking abilities that are essential to prioritising, planning and
providing safe and effective patient centred, nursing care.
Task:
In this Clinical Case Study, you will be required to select one
(1) of the nursing problems provided below, discuss its
relevance, then plan and evaluate patient centred, nursing care.
The nursing problems all relate to Darren Roberts’ care in the

first 4 hours of his discharge from PARU and return to the ward
following his surgery.
Instructions:
Nursing Problem Statements [choose one (1) for your
discussion]
· Potential for respiratory depression related to anaesthesia and
opioid medications and would be evidenced by respiratory rate
<10Rpm, SpO2<95%on RA and shallow breathing.
· Potential for hypovolemia related to fluid deficit and blood
loss intraoperatively and would be evidenced by Pale, cold and
clammy skin, decreased urine output, BP >90/60 and respiratory
rate > 20Rpm.
· Risk of Nausea and/or Vomiting related to anaesthesia and
opioid medications and would be evidenced by complaints of
nausea and observed or reported vomiting
Required Sections
1. Discuss the importance of the Nursing Problem you have
chosen and why it is a particular risk for Darren in the first 4
hours of his return to the surgical ward.
· Use Darren’s data and documentation from the Enquiry to
inform this discussion; this does not require APA6 referencing.
· Use evidenced based nursing literature to support your
discussion; this does require APA6 referencing.
Approximately 500 words

2. Write one Patient Centred SMART Goal for Darren’s Nursing
Problem that you have selected. Approximately 1 to 2 sentences
3. Provide three (3) relevant Nursing Interventions designed to
achieve the selected SMART Goal.
Discuss each intervention separately and include evidenced
based rationales for the intervention; this does require APA6
referencing. Approximately 600 words (200 for each
intervention)
4. Discuss the evidenced based assessments you would use to
evaluate the effectiveness of implemented nursing
interventions; this does require APA6 referencing.
Approximately 400 words
Format:
· Ensure your name and student ID are clearly marked on your
wish.
· Where you have been asked to ‘discuss’ will be expected to
write in academic fashion. i.e. –not use bullet points, but
paragraphs and sentences.
· Use APA6 referencing throughout –except when using
Darren’s documentation provided on the LMS.
· Reference list in APA6 style to be included.
· Suggested word count for each section is a guide only.
· You are not required to provide either an introduction or a
conclusion.
· You do not have to submit the marking rubric, as we will be
using the Turnitin rubric for feedback.
Hyperlinks: Referencing Tool,Referencing at LaTrobe
General information: (hyperlinks to details in Subject Learning
Guide)
· Academic Integrity/Originality

· Submission details/Turnitin
· Extensions
· Penalties
Refer to http://www.latrobe.edu.au/policy/for information
about:
· Extension to Submission Dates
· Late Submission of Assessment Tasks
· Special Consideration
· Academic Integrity
· Academic Progress
· Assessment and Feedback
· Occupational, Health and Safety [OHS]
· Privacy
· Student Charter
· Use of Electronic Mail
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