Foundations of health assessment

Foundations of health assessment

Student Portfolio Workbook Template

Instructions

Read the assessment brief document before completing this template.

Answer all 4 workbook sections on this template in the spaces provided.

Do not alter the template or delete text.

Ensure that you answer questions according to the assessment brief

Review the rubric before submission.

Word count guides have been provided for each section of the workbook.

A reference list is to be added under the heading Reference List at the end of the template.

This assessment task is a collection of four individual 250-word activities, that will be presented in a workbook format, informed by the first 4 modules. This assessment template will be submitted by the student as a complete portfolio via Turnitin at the start of week 5.

Workbook 1: Data management techniques to document holistic healthcare:

left191770Scenario: Today, you have been assigned to a new patient, Mrs. Joy, who has just been admitted to the ward with pneumonia.

When you arrived at Mrs. Joys room, you introduced yourself and explained your role in her care. You then proceeded to take her vital signs. You noticed that Mrs. Joys breathing was laboured and elevated, and her temperature was slightly elevated. Whilst not yet out of range to call a rapid response, you are concerned that Mrs. Joy is showing early signs of deterioration.

You decide to call the doctor in charge of Mrs. Joys care to report your observations and concerns, and the doctor orders an oral medication to help reduce her fever. You prepare the medication and explained to the patient how, and why to take it.

You perform the 9 rights and 3 checks of medication safety, however, as you hand her the medication, you notice a fearful expression on her face. You gently reassured her and help her with a glass of water to take the medication. You stay with Mrs. Joy for a few more minutes, making sure she is comfortable, answering any questions she has.

Before leaving the room, you document observations and the medication administration in Mrs. Joys chart.

00Scenario: Today, you have been assigned to a new patient, Mrs. Joy, who has just been admitted to the ward with pneumonia.

When you arrived at Mrs. Joys room, you introduced yourself and explained your role in her care. You then proceeded to take her vital signs. You noticed that Mrs. Joys breathing was laboured and elevated, and her temperature was slightly elevated. Whilst not yet out of range to call a rapid response, you are concerned that Mrs. Joy is showing early signs of deterioration.

You decide to call the doctor in charge of Mrs. Joys care to report your observations and concerns, and the doctor orders an oral medication to help reduce her fever. You prepare the medication and explained to the patient how, and why to take it.

You perform the 9 rights and 3 checks of medication safety, however, as you hand her the medication, you notice a fearful expression on her face. You gently reassured her and help her with a glass of water to take the medication. You stay with Mrs. Joy for a few more minutes, making sure she is comfortable, answering any questions she has.

Before leaving the room, you document observations and the medication administration in Mrs. Joys chart.

Nursing note activity; Now its time for you to have a go!

Workbook 1 Part A Nursing Note (100 words)

Students are to write a short nursing note based on an example of care provided in the scenario below. Consider the information presented in Topic 4 of this module (Module 1) as you document the episode of care. Your nursing note should be 100 words maximum.

Workbook 1 Part B - Reflective Writing (150 words)

Please review activity 4.1 in Module 1 The Dos and Donts of Documenting, and tell us in a mini reflection how you have applied guidelines of high-quality documentation to your nursing note. At least 1 high quality, peer reviewed reference is required to support your statements as to how your example is in line with evidence-based best practice in documentation.

Workbook 2: Pathophysiology concepts as related to nursing assessment: Airway, Breathing & Circulation.

Please review the case study below regarding Emily and her recent exacerbation of Asthma. Your task is to thoroughly analyse Emily's case study and provide 2 short responses to the questions below. You must demonstrate an exceptional level of knowledge about the pathophysiology of asthma and its potential outcomes or complications for the patient. Ensure your discussion is evidence-based and relevant, utilizing a diverse range of high-quality sources to support your points.

00Presenting Complaint

Emily is a 22-year-old female who presents to the emergency department with increasing shortness of breath, chest pain and an audible wheeze.

Over the last three months, Emily has noticed a significant increase in her asthma symptoms. She experiences more frequent episodes of wheezing, coughing, chest tightness, and shortness of breath, which are interfering with her daily activities, including attending classes and exercising.

Patient Background:

Emily was diagnosed with asthma at the age of 12 and has been managing it with a salbutamol inhaler and occasional oral corticosteroids as needed.

Clinical Observations:

On assessment, Emily appears to be in mild respiratory distress. She has a Respiratory rate of 22 breaths per minute. Widespread wheeze on auscultation. Oxygen saturations of 93% on room air. Her heart rate is 115 beats per minute but is regular on palpation. Her blood pressure is 130/70.

An exacerbation of Asthma was suspected and when obtaining a more detailed history of Emilys medical background, you learn that she started experimenting with vaping nicotine-containing e-cigarettes about six months ago, initially on social occasions and eventually becoming a regular vaper, consuming approximately one pod per week.

On Assessment:

Based on the clinical presentation and history, a diagnosis of acute exacerbation of asthma was made. Emily was given inhaled short-acting beta-agonists, oxygen therapy, and systemic corticosteroids. She was closely monitored for improvement in her symptoms and for potential adverse effects of the therapy provided.

After about an hour, Emilys respiratory rate decreased to 16 breaths per minute, and oxygen saturation improved to 97% on room air. Her heart rate was now 95 beats per minute and her blood pressure remained stable - 122/60. On auscultation, her breath sounds became clearer and more equal throughout all lung fields. Her wheezing has also improved. After 6 hours in the emergency department, Emily was discharged with a prescription for a short term, increased dose of inhaled corticosteroids and a new asthma action plan.

0Presenting Complaint

Emily is a 22-year-old female who presents to the emergency department with increasing shortness of breath, chest pain and an audible wheeze.

Over the last three months, Emily has noticed a significant increase in her asthma symptoms. She experiences more frequent episodes of wheezing, coughing, chest tightness, and shortness of breath, which are interfering with her daily activities, including attending classes and exercising.

Patient Background:

Emily was diagnosed with asthma at the age of 12 and has been managing it with a salbutamol inhaler and occasional oral corticosteroids as needed.

Clinical Observations:

On assessment, Emily appears to be in mild respiratory distress. She has a Respiratory rate of 22 breaths per minute. Widespread wheeze on auscultation. Oxygen saturations of 93% on room air. Her heart rate is 115 beats per minute but is regular on palpation. Her blood pressure is 130/70.

An exacerbation of Asthma was suspected and when obtaining a more detailed history of Emilys medical background, you learn that she started experimenting with vaping nicotine-containing e-cigarettes about six months ago, initially on social occasions and eventually becoming a regular vaper, consuming approximately one pod per week.

On Assessment:

Based on the clinical presentation and history, a diagnosis of acute exacerbation of asthma was made. Emily was given inhaled short-acting beta-agonists, oxygen therapy, and systemic corticosteroids. She was closely monitored for improvement in her symptoms and for potential adverse effects of the therapy provided.

After about an hour, Emilys respiratory rate decreased to 16 breaths per minute, and oxygen saturation improved to 97% on room air. Her heart rate was now 95 beats per minute and her blood pressure remained stable - 122/60. On auscultation, her breath sounds became clearer and more equal throughout all lung fields. Her wheezing has also improved. After 6 hours in the emergency department, Emily was discharged with a prescription for a short term, increased dose of inhaled corticosteroids and a new asthma action plan.

Workbook 2: Short Response Questions

Workbook 2 Question 1: (150 words)

Please outline the links between the pathophysiological mechanisms of asthma and the specific events described in the case study, referencing scholarly sources to support your explanation.

Workbook 2 Question 2: (100 words)

Briefly identify potential complications that may arise for the patient in this case study, referencing scholarly sources to support your explanation.

Workbook 3: Pathophysiology concepts as related to nursing assessment: Disability, and Exposure.

Please review the case study below regarding Archie. Your task is to thoroughly analyse Archies case study and provide 2 short responses to the questions below. You must demonstrate an exceptional level of knowledge about the pathophysiology of Crohns Disease and its potential outcomes or complications for the patient. Ensure your discussion is evidence-based and relevant, utilizing a diverse range of high-quality sources to support your points.

left337820Archie, a 65-year-old man, was admitted to the hospital for management of a colostomy-related complication. He had a history of Crohns Disease and had undergone surgery to create a colostomy. However, he recently developed skin breakdown around the stoma, which had become increasingly painful and infected, resulting in this hospital admission.

Upon assessment, the nurse observed erythema, excoriation, and maceration of the skin surrounding the stoma site. Archie stated the site was causing him increased pain and discomfort. The nurse first focused on managing the patient's pain, which was interfering with her ability to tolerate cares. The nurse recognized the need for immediate intervention to prevent further skin damage and to promote healing. The underlying cause of the skin breakdown was identified to be from leakage from the ill-fitting stoma appliance. The specialist stoma nurse attended and assessed both the stoma site and the equipment being used, before providing education to the patient about proper stoma care techniques and instructed her on how to monitor for signs of leakage.

0Archie, a 65-year-old man, was admitted to the hospital for management of a colostomy-related complication. He had a history of Crohns Disease and had undergone surgery to create a colostomy. However, he recently developed skin breakdown around the stoma, which had become increasingly painful and infected, resulting in this hospital admission.

Upon assessment, the nurse observed erythema, excoriation, and maceration of the skin surrounding the stoma site. Archie stated the site was causing him increased pain and discomfort. The nurse first focused on managing the patient's pain, which was interfering with her ability to tolerate cares. The nurse recognized the need for immediate intervention to prevent further skin damage and to promote healing. The underlying cause of the skin breakdown was identified to be from leakage from the ill-fitting stoma appliance. The specialist stoma nurse attended and assessed both the stoma site and the equipment being used, before providing education to the patient about proper stoma care techniques and instructed her on how to monitor for signs of leakage.

Workbook 3: Short Response Questions

Workbook 3 Question 1: (150 words)

Please outline the links between the pathophysiological mechanisms of Crohns Disease and the specific events described in the case study, referencing scholarly sources to support your explanation.

Workbook 3 Question 2: (100 words)

Briefly identify potential complications that may arise for the patient in this case study, referencing scholarly sources to support your explanation.

Workbook 4: Data management techniques to document holistic healthcare: Literature for documenting health assessments.

Four, high quality, peer-reviewed articles have been selected for you to choose from for this activity. They are listed below. You must CHOOSE ONE article from here before completing the steps in the workbook 4 template section below.

ARTICLES:

Australian Commission on Safety and Quality in Health Care. (2020). Communicating for safety standard: Documentation and information. National Safety and Quality Health Service Standards. https://www.safetyandquality.gov.au/standards/nsqhs-standards/communicating-safety-standard/documentation-informationAustralian Nursing & Midwifery Journal. (2019, August 26). The Coroner's Court: Extracting Tips for Improved Documentation. https://anmj.org.au/the-coroners-court-extracting-tips-for-improved-documentation/James Cook University (2021). Introduction to Documentation. In Nursing Documentation (pp. 1-3). JCU Pressbooks. https://jcu.pressbooks.pub/nursingdocumentation/chapter/introduction-to-documentation/Ahn, M., Choi, M., & Kim, Y. (2016). Factors Associated with the Timeliness of Electronic Nursing Documentation.Healthcare informatics research,22(4), 270276. https://doi.org/10.4258/hir.2016.22.4.270

Please choose ONE of the articles provided above, and identify with a heading e.g.: Article 1

Analyze what key message the article is telling you about the importance of the documentation type discussed, and why is it important? Include a description of what crucial messages or main points can be drawn from the article? You must use two additional high quality, peer reviewed references to support your statements in line with evidence-based best practice in documentation.

(250 words)

Write your reference list below:

Reference list