Student Name Student Number Unit Code/s & Name/s HLTENN037 Perform clinical assessment and contribute to planning nursing care
Student Name Student Number Unit Code/s & Name/s HLTENN037 Perform clinical assessment and contribute to planning nursing care
HLTENN038 Implement, monitor, and evaluate nursing care
Cluster Name If applicable CLS-HLT-0071 Clinical Assessment and Care Planning Cluster
Assessment Type Case Study Assignment Project Other (specify)
Assessment Name Written questions and Case studies Assessment Task No. 2 of 4
Assessment Due Date Date Submitted / /
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Student Signature Date / /
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Instructions to Student General Instructions:
Read the general and workplace simulated case scenarios on the following pages and answer all questions.
Please review the marking criteria for this assessment to ensure you are providing the required information in your answers.
All parts of each question are to be answered. APA referencing is to be used for all answers.
When you are answering your questions, type the answer below each question. You may choose to put the question in bold format if you wish. Please do not change the font.
Information / Materials provided:
Open Book - to be completed on their own and submitted by the due date as stated in the unit guide
Access to a computer and word processing software is required.
Assessment Criteria:
To achieve a satisfactory result, your assessor will be looking for your ability to demonstrate the following key skills/tasks/knowledge as outlined in the marking criteria for this assessment task.
Number of Attempts:
You will receive up to two (2) attempts at this assessment task. Should your 1st attempt be unsatisfactory (U), your teacher will provide feedback and discuss the relevant sections / questions with you and will arrange a due date for the submission of your 2nd attempt. If your 2nd submission is unsatisfactory (U), or you fail to submit a 2nd attempt, you will receive an overall unsatisfactory result for this assessment task. Only one re-assessment attempt may be granted for each assessment task.
For more information, refer to the Student Rules.
Submission details Once completed, you upload the assessment to the AT1 drop box in Connect, ensuring that you follow the instructions carefully (there is an instruction video on the screen). If you are experiencing difficulties uploading your paper, contact your teacher before the due date.
If you are unable to submit by this date, you must ask for an extension in writing at least 48 hrs before the due date. You can download an extension request form on CONNECT. Requests for extensions inside this seven-day deadline will not be approved unless you have a medical certificate.
TAFE Queensland Learning Management System: Connect url: https://connect.tafeqld.edu.au/d2l/loginUsername; 9 digit student number
For Password: Reset password go to https://passwordreset.tafeqld.edu.au/default.aspxFile Name:
You should save this file in the following format (including the month and year your course started. This enables your teacher to download your assessments in alphabetical order:
Your Surname_group_Number of assessment.
Example: Wilson_Apr 2019_AT1
If you are required to resubmit an assessment, please name your files as follows:
Your Surname_resubmit_group_number of assessment.
Academic and Research Misconduct:
APA 7th edition style in-text referencing must be used throughout, and a reference list submitted with the assessment. Students must use their own words to answer the questions. Assessments that use, reproduce, or adapt the work or ideas of another person without due acknowledgment will be graded as unsatisfactory and considered academic misconduct. For more information, refer to the Student Rules
Instructions for the Assessor Students are to attempt all assessment questions / tasks and submit for review and resulting by the due date. Please refer to QLD TAFE Student Rules and Policies for assessment and appeals processes:
https://tafeqld.edu.au/about-us/policy-and-governance/policies-and-procedures/student-rules-and-policies/index.html
Students are expected to complete unit content and personal study to assist in completing the assessment successfully.
Assessors are to refer to the Benchmark Answers to ensure objectivity and consistency.
Tafe assessor is to refer to Tafe Student Support Strategy if reasonable adjustment is required
https://intranet.tafeqld.edu.au/sites/search/Pages/intranetresults.aspx?k=reasonable%20adjustmentAll aspects of the marking criteria must be met in order to achieve a satisfactory result for this assessment.
Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors.
Note to Student An overview of all Assessment Tasks relevant to this unit is located in the Unit Study Guide.
Case study - Mrs Soo Hui - relates to Q1-19
Mrs Soo Hui is a 46-year-old female ( identifies as she, her) admitted to your ward at St Elsewhere Hospital, following an incidence of blurred vision, numbness down the right side and a sharp pain in her head. The next-door neighbour found her on the ground outside her front door unable to move or speak.
She has been diagnosed as having a left sided ischaemic cerebro-vascular accident. She was immediately commenced on anti-coagulant therapy.
Family history
Born to Thai parents in Australia
Buddhist & speaks Thai & English
Lives with husband & 2 children, Ty 13 years old & Grace 5 years old. Also her father who is a frail 82-year-old. Medical history
Hypertension, Type 2 Diabetes, Asthma
Depression
Hearing aid left ear
Bi-focal glasses (broken in fall)
Upper dental partial plate
Medication - Amlodipine, Metformin, Salbutamol.
Admission observations
BP 150/90
PR 85 regular
RR 24
To 36.9
SpO2 96% on room air
BGL 8.4 mmol
Weight 69 kg
Height 162 cm
GCS (Glasgow coma scale) = 14
Eyes open to speech
Oriented to time, place, and person (speech slurred, but able to be understood)
Right hemiparesis
PERL (Pupils equal reactive to light) Issues/impacts of the CVA
Pain on movement, mainly right hip & shoulder stated as 7 /10
Large haematoma right hip
5cm skin tear right elbow
Dysphasia
Dysphagia
Right sided facial droop
Mild Right-side hemiplegia
Initial Doctors orders and interventions
Rest in bed (RIB)
2nd hourly Neurological observations
Nil by mouth (NBM) until Speech Therapist review
Physiotherapist review
Full assistance with hygiene
IDC insitu
Intravenous Therapy via cannula in left forearm Discharge Information
Mrs Soo Hui will remain in acute care for two (2) weeks and then be transferred to the Rehabilitation Unit for intensive physiotherapy and occupational therapy. Community Services and the Discharge Planning team have been contacted.
Provide an answer for each of the questions below in relation to Mrs Hui.
Explain how you would prepare the hospital room for Mrs Huis admission to the ward. List 4 pieces of equipment you would need to conduct an assessment on Mrs Huis when she is admitted to the ward. Identify 4 components of correct nursing documentation ( this also includes electronic documentation) Why is it important to measure and record a person weight and height on admission? You are required to provide a clinical handover to the Enrolled Nurse and Registered Nurse who are coming onto the next shift.
Using the ISBAR format, what information would you include when doing a verbal bedside clinical handover for Mrs Hui?
I S B A R
Mrs Hui has had an Ischaemic cerebrovascular accident (CVA). Answer the following questions.
Explain the two types of CVA, including where it occurs and what causes it. Identify four (4) indications of a left sided CVA. Identify the other morbidities / co-morbidities that Mrs Hui has. Mrs Hui is 46 yrs of age, discuss how depression can affect a person in middle adulthood. The RN has created care plans for Mrs Hui and identified four (4) assessment and nursing diagnoses based on the Nursing process concept.
As the EN contributing to the nursing care plan, please provide the following for each of the four (4) care plans.
Two (2) nursing implementations for each care plan.
One (1) rational and one (1) evaluation for each Implementation.
a)Care Plan 1
Assessment (subjective and objective data) (completed by RN)
Rest in bed, Actual identification of limited Immobility due to CVA
Nursing diagnosis (Identification) (completed by RN)
Risk of impaired skin integrity related to immobility resulting from CVA
Planning (goal, expected outcome, what do you hope to achieve) (completed by RN)
implement nursing cares to prevent risks of altered skin integrity
Implementation (nursing care interventions, what action can you as the EN can do) Rationale (reason why)
One (1) for each implementation Evaluation (did the plan of care work, how will you know)
One (1) for each implementation
1.
2.
b)Care Plan 2
Assessment (subjective and objective data) (completed by RN)
Pain, limited movement, and bed rest
Nursing diagnosis (Identification) (completed by RN)
Inability to perform self-care hygiene independently
Planning (goal, expected outcome, what do you hope to achieve) (completed by RN)
Patients personal and oral hygiene needs will be met
Implementation (nursing care interventions, what action can you as the EN can do) Rationale (reason why)
One (1) for each implementation Evaluation (did the plan of care work, how will you know)
One (1) for each implementation
1.
2.
c)Care Plan 3
Assessment (client has/has not, data) (completed by RN)
Mrs Hui has been placed on a puree diet by the Doctor, she is noted to have difficulty eating due to Right hemiparesis
Nursing diagnosis (Identification) (completed by RN)
Risk for aspiration related to impaired swallowing reflex resulting from CVA
Planning (goal, expected outcome, what do you hope to achieve) (completed by RN)
Nursing staff to provide supervision and assistance with eating and drinking where there is clinical risk
To minimise risk of aspiration while maintaining optimal nutritional and hydration status.
Implementation (nursing care interventions, what action can you as the EN can do) Rationale (reason why)
One (1) for each implementation Evaluation (did the plan of care work, how will you know)
One (1) for each implementation
1.
2.
d)Care Plan 4
Assessment (client has/has not, data) (completed by RN)
Mrs Hui is expressing feelings of powerlessness and loss of control over her limited mobility due to CVA and being away from her family
Nursing diagnosis (identification) (completed by RN)
Risk for impaired emotional, psychological, and social function related to depressed mood and impact of major health event (CVA)
Planning (goal, expected outcome, what do you hope to achieve) (completed by RN)
Reduced feelings of depression and creating adaptive measures
Implementation (nursing care interventions, what action can you as the EN can do) Rationale (reason why)
One (1) for each implementation Evaluation (did the plan of care work, how will you know)
One (1) for each implementation
1.
2.
Later in the week following admission, Mrs Hui has had her IDC removed.
You are looking after Mrs Hui and she states she feels a burning and stinging sensation when she passes urine, you perform a urinalysis, and these are the results.
Colour Odour Glucose Bilirubin Ketones Specific gravity (SG) Blood pH Protein Urobilinogen Nitrite Leucocytes
Cloudy Offensive Nil Nil Nil 1.025 Nil 8.5 Nil Normal range yes yes
Identify which of these results are outside normal range and what might these abnormalities indicate?
Mrs Hui is now able to sit out of bed and be taken to the toilet on a commode chair, however, remains incontinent of urine and faeces at times.
Provide four (4) nursing care interventions you can do to promote continence and manage incontinence for Mrs Hui.
Intervention 1 Intervention 2 Intervention 3 Intervention 4 Provide three (3) examples of urinary and faecal incontinence aids (other than an Indwelling catheter) for both men and women.
Mrs Hui requires assistance with her personal hygiene cares as she still has limited mobility due to her CVA.
You are required to assist Mrs Hui in the shower, Mrs Hui will be sitting on a shower chair.
Provide a nursing action for each personal care listed in the table.
Personal hygiene care need Identify one (1) nursing action you would do for each Personal hygiene care need.
Basic eye care Cleaning Mrs Hui ears Cleaning Mrs Huis hearing aid Mrs Hui requires you to clean her upper denture Outline three (3) reasons why it is important for the nurse to ensure Mrs Huis hygiene and grooming needs are met.
You are working night duty and when you go into see Mrs Hui, she is wide awake, she tells you that she has a lot of trouble getting comfortable and sleeping at night
List two (2) factors that impede sleep, comfort, and rest and two (2) factors that promote comfort, sleep, and rest.
Factors that impede (state 2) Factors that promote (state 2)
Comfort Sleep/rest Mrs Hui will be in hospital and rehabilitation for an extended period of time. Assessments will need to be done to ensure that her environment is safe to assist in her recovery.
Outline two (2) nursing actions that can be implemented to maintain a safe environment for Mrs Hui during her lengthy stay in hospital and rehabilitation.
State the documentation required to assist in the prevention of falls for Mrs Hui.
Outline two (2) actions to promote and encourage active and passive exercises for Mrs Hui while on bed rest.
Outline two (2) actions to promote and encourage effective breathing for Mrs Hui while on bed rest.
Mrs Hui has been the main person who cares for their two children and her father as Mr Hui works long hours. Now that Mrs Hui is in hospital, Mr Hui has taken leave from work to assist at home and support his wife. Mr Hui however is unsure what daily activities and nutritional needs he should be providing for his children and father-in-law.
Identify two (2) recommendations to Mr Hui in regards to physical activity requirements for 5- and 13-year-old children.
Identify two (2) recommendations to Mr Hui in regards to physical activity requirements for his 82-year-old father-in-law.
Mr Hui would like to ensure that he is providing nutritious meals to his daughter, son, and father-in-law.
Identify two (2) nutritional facts for pre-schoolers, adolescents and elderly that Mr Hui may use to ensure that he is providing nutritious meals to his children.
Group Two (2) nutritional facts for each group
Pre-schoolers AdolescentsElderly On one particular day when Mr Hui is visiting his wife, he indicates to you that he feels the need for physical & emotional support as he is feeling overwhelmed with his wife being in hospital and caring for his children and father-in-law.
What advice could you provide for Mr Hui and other family members or carers in similar situations that may assist both emotional and physical needs to improve wellbeing.
Mrs Hui is being prepared for discharge.
Please answer the following questions.
When should the discharge plan for Mrs Hui begin? Outline three (3) elements that should be part of the discharge summary form Identify to (2) community support services or resources that can assist Mrs Huis discharge.
Case study - relates to Q20
Olivia a 49-year-old female patient (identifies as she, her) is day 2 following a laparoscopic cholecystectomy (removal of Gallbladder). She has a 25-year history of Type 1 Diabetes Mellitus.
She remains hospitalized for observation following a decreased urinary output and a temp of 38.6 on her first post-operative day. She received her routine morning dose of Insulin as per her medication chart before her breakfast arrived at 7am.
At 9am Olivia uses her call bell, you respond, and she states she is feeling nauseated and dizzy, you also note she appears to be sweating, she states she had not eaten her breakfast as she felt nauseated.
Answer the questions below
What are the signs and symptoms of Hypoglycaemia? List three (3) nursing actions you may take as a student Enrolled Nurse. How soon do you report Olivias situation and who do you report to? How soon after taking vital signs do you document them on the observation chart.
Case study - relates to Q21
Jim a 54-year-old male (identifies as he, him) is admitted to your hospital ward for a colonoscopy; he is completing his bowel preparation (2 Litres of Colonlytely) and is due for the scope the following morning. He has a family history of bowel cancer, previous medical history of ischemic heart disease and hypertension.
Jim has been stressed about having the procedure and has felt nauseated since drinking the bowel preparation.
When returning from the bathroom to his bed, Jim feels breathless and clutches his chest, he reaches out to buzz the nurse, after pressing the buzzer he falls onto the floor near his bed. You respond to the buzzer and find Jim on the floor, unresponsive.
Using the ARC guidelines for DRSABCD what you do.
Basic Life support
State what each Letter represents Outline what you would do for each Letter in regards to Jim
D - R - S - A - B - C - D -
Answer the following questions.
What are three (3) signs and symptoms for mild to moderate allergic reactions. What are three (3) signs and symptoms for severe allergic reactions (Anaphylaxis). Identify three (3) Enrolled Nursing actions if a person suffers from a severe allergic reaction. Mia, a 24-year-old African woman, was admitted to the hospital ward following investigations of severe abdominal pain. Mia has a severe intolerance to lactose and has no dairy in her current diet, doesnt take supplements and suffers from Amenorrhea. Her doctor has discussed calcium supplement tablets, but Mia thinks they are too big to swallow and expensive.
Answer the following questions.
What effect on the body does severe lactose intolerance have, and what nutrient is Mia deficient in? As a EN what diet advice and care could you recommend to Mia? Who could you refer Mia to? Cheryl Johnson is a 79-year-old woman with Alzheimers disease. She lives in a residential aged care facility in central Queensland. Recently she has started having conversations with her husband who has been dead for 20 years, she is having trouble recognising her daughter when she visits and also staff, she frequently becomes agitated towards the evening and when anyone asks her to do something.
Identify three (3) nursing actions you can do to help reassure and settle Cheryl.
End of Assessment
