HLT54115 Diploma of Nursing | My Assignment Tutor

Assessment Type:Assessment Title:35821/05 Implement, monitor and evaluate nursing care plans Case StudyDate:     Student Name:     Cohort:     Open Colleges Student ID:E      Attempt       In order to demonstrate competence in units of competency within the HLT54115 Diploma of Nursing, a combination of assessment tasks must be completed to demonstrate an understanding of the underpinning knowledge and required skills as outlined in the National Training Package. The following HLTEN004 Implement, monitor and evaluate nursing care plans assessment must be completed to form part of the evidence required to demonstrate the underpinning knowledge for: HLTENN004 Implement, monitor and evaluate nursing care plans Timeframe: This assessment must be completed by Week 60 in your timetable. Grading: Each assessment task will be graded Satisfactory (S) or Not Yet Satisfactory (NYS). A Satisfactory result in each assessment task must be attained to receive a competent outcome for the unit overall. For information regarding reassessment refer to the Student Handbook. “I affirm that all work submitted within is my true and original work unless otherwise credited” Student signature:       Date       ☐ If you have typed your name, please tick this box to acknowledge that by including your name in place of a signature above, it is deemed to be your signature for the purpose of this assessmentModule 23 HLTENN004 Implement, monitor and evaluate nursing care plans. This is assessment 5 of 5 Deliverables/To do list: Complete the assessment coversheet by adding: Your full name Open Colleges Student ID Date Your Cohort (eg Feb 19) Affirm that the work submitted is your work, either by: Signing the bottom of the page (this can be an electronic signature) or Tick the affirmation box and type your name. Read the student instructions and complete all parts to this assessment. Before submitting all parts of this assessment into OpenSpace, ensure you read and follow the deliverables set out in this assessment. Save all documents using the naming convention:‘Your Surname_your open colleges student number_assessment number.doc’. For example: “SMITH_E1234569_31135_01.doc.” Save a copy of this assessment for your own records and upload your assessment into OpenSpace using the relevant assessment upload link in this module. Background/Overview  This unit describes the skills and knowledge required to implement nursing care as outlined in a person’s plan of care, evaluate outcomes of care provided, record and report progress. Within this assessment, you are asked to demonstrate knowledge around specific aspects of Maida LONGBRIDGE’s episode of care. Instructions to the student This assessment will comprise four (4) parts. Part A – Short answer knowledge-based questions relating to Maida Longbridge’s carePart B – Responses to Maida Longbridge’s Nursing care planPart C – Short answer knowledge-based questions relating to Maida Longbridge’s carePart D – Practical skills relating to caring for Maida Longbridge During this assessment, you are required to demonstrate the following: Part A – Short answer knowledge-based case study questions You are required to read the case study background information on Maida Longbridge and use this information to answer the twenty-five (25) questions relating to their care. The answers you provide should be related to the patient information provided and all rationales of care should relate to her specific needs. You are to: Answer the questions from the perspective of a qualified Enrolled Nurse.Use correct anatomical and medical terminology in your answers.Reference your answers using the APA 6th Edition referencing standard. Note: This part of the assessment must be completed before undertaking Part B. Part B – Nursing Care Plan You are required to read the case study background information on Maida Longbridge and use this information to complete Maida’s Nursing Care Plan relating to risk prevention strategies. The answers you provide should be related to the patient information provided and all rationales of care should relate to Maida’s specific needs. You are to: Answer the questions from the perspective of a qualified Enrolled Nurse.Use correct anatomical and medical terminology in your answers.Reference your answers using the APA 6th Edition referencing standard. Note: This part of the assessment must be completed before undertaking Part C. Part C – Short answer knowledge-based case study questions You are required to read the case study background information on Maida Longbridge and use this information to answer the five (5) questions relating to their care. The answers you provide should be related to the patient information provided and all rationales of care should relate to Maida’s specific needs. You are to: Answer the questions from the perspective of a qualified Enrolled Nurse.Use correct anatomical and medical terminology in your answers.Reference your answers using the APA 6th Edition referencing standard. Note: This part of the assessment must be completed prior to undertaking Part D. Part D – Practical skills You are required to read the case study background information on Maida Longbridge and use this information to demonstrate knowledge and rationales as to why the following skills would be important nursing interventions when caring for Maida. The practical skills component of this assessment will take place in the clinical skills lab at a time advised by your educator. You will be required to print this assessment before attending campus. The three (3) skills to be demonstrated as part of this assessment are as follows: Clinical Skill 19.4 Assessment of Venous Thromboembolism Assessment (page 40-41)Clinical Skill 19.5 Assessment of Nutrition Assessment/ Weight, Height and BMI (page 45 -46)Clinical Skill 25.3 Assessment of Incentive Spirometry (page 214-215) The practical skills you will be assessed on will be conducted against the competency checklists provided in the textbook (unless indicated otherwise): Koutoukidis, G. and Stainton, K (2017). Essential enrolled nursing skills for person-centred care. 7th Ed. Sydney: Elsevier Australia. The skills will be simulated with a mannikin representing the patient. During your practical skills,your educator will ask and discuss with you your rationales for your nursing actions and ask clarifying questions as this will encourage you to think critically, problem-solve, and identify the evidence that underpins your knowledge. Deliverables for this assessment To gain a satisfactory result for this assessment, you will need to upload all the following documents into OpenSpace in one submission. Your OpenSpace assessment submission is to include: You completed assessment coversheetPart A – Your completed responses to the short answer questions related to risk identification and prevention strategies associated with Maida’s episode of care.Part B – Your completed responses to Maida Longbridge’s Nursing care planPart C – Your completed responses to the short answer questions on Maida LongbridgePart D – Copies of your three (3) clinical skills checklists, (completed, assessed and signed) which you were assessed on campus. Once uploaded, your educator will assess your assessment submission and provide feedback to you on the Assessment Evidence Checklist attached to this assessment. You will be given either a Satisfactory or Not Yet Satisfactory result. If your result is Not Yet Satisfactory, you will be given a due date for resubmission and feedback indicating what areas need addressing to gain a satisfactory result. Case study background information – Maida LONGBRIDGE Maida is a 73-year-old lady who lives independently at home with her partner, Glenda. Maida was standing on the ladder cleaning their front gutters and as she was coming down the ladder lost her footing and fell on her left side from 40cm above the ground. Maida called out to Glenda who assisted Maida to her feet. Glenda phoned the GP surgery who advised her to call for an Ambulance to take Maida to Care Shore Hospital. The Ambulance arrives and assesses Maida, IVA is established and NaCL 0.9% is commenced. Maida has a 12 lead ECG recorded and she is transported to Care Shore Hospital. Currently, the Ambulances are banked up and there is a one (1) hour wait. Maida remains in the Ambulance whilst waiting to be transferred to the ED. On presentation to the ED, Maida is alert and orientated. She looks pale and is cool to touch, her L) Leg is externally rotated and shortened, and her pain score is 9/10 radiating down her L) Leg. Maida is administered Intranasal Fentanyl as per the “fractured hip protocol.” Past Medical History: Depression and Anxiety (diagnosed 30 years ago as a result of childhood trauma) Anorexia Nervosa Spontaneous L) Calf DVT 2 years ago. Medication Nil medication is taken 1800 Maida’s vital signs are as follows: Temperature: 36.8oCBP: 175/90 mmHgPulse: 62 beats per minuteRespirations: 26 breaths per minuteSpO2: 92% on airPain Score: 9/10, L) hipGCS: 14 As per the Hip Fracture pathway, Maida has the following diagnostics taken: PathologyECGMedical ImagingFBE12 lead ECGAP PelvisType and ScreenLateral Oblique L) HipCOAGAP and Lateral L) long FemurU & EChest XRAY Glenda arrives shortly after Maida is transferred into the ED. 2000 Maida is diagnosed with a sub-capital fracture of her Left Neck of Femur. No Theatre time is available this evening due to multiple emergency cases. Maida is to be transferred to the orthopaedic ward and surgery is planned for 0800 tomorrow. Maida and the ED Medical Officer complete a Resuscitation Plan. Maida is to commence on the Fractured Hip Clinical Pathway and a referral is sent to the Orthogeriatric team. She is transferred from the ED to your ward at 2030. She has been written up for the following pre-operative orders: Pre-operative orders- Nursing observations – T, P, R, BP, Sp02, Pain Score, Sedation ScoreNeurovascular Observations (L and R) LegsPO 500mg – 1gram Paracetamol, 6 hourly maximum of 4g in 24 hoursPO 5 – 10mg Oxycodone 4hrly prnRoutine medications upon consultation from the Orthogeriatrician; –VTE Prophylaxis – S/C Clexane 80mg BDFluid balance chart.High protein, high energy diet with nourishing mid meals, snacks or drinks, unless contraindicated until the patient receives a nutritional screening.Malnutrition Universal Screening Tool (MUST) on admissionOral Health Assessment- baseline on admission and each shiftDelirium assessment – baseline on admission and each shift and cognition declineFalls risk assessment every shiftBraden Score 2 hourlyAbbreviated Mental Test (AMT) screening toolDynamic pressure-relieving mattressPreparation for surgery as directed by the patient’s multi-disciplinary team.Discharge PlanDaily multi-disciplinary team (MDT) meeting Part A – Short answer knowledge-based case study questions Related to risk identification and prevention strategies associated with Maida’s episode of care. Performance criteriaRecord of resultsQ1Discuss how Maida’s age could increase her risk of post-operative complications.SNYSStudent to add answer hereQ2State two (2) post anaesthetic risks that Maida could experience.SNYSStudent to add answer hereQ3State two (2) postoperative risks for a patient undergoing surgery to repair of a #NOF.SNYSStudent to add answer hereQ4Outline how you would assess Maida’s Cognitive status post administration of PO Oxycodone 10mg.SNYSStudent to add answer hereQ5State 1 (one) nursing intervention that assists in reducing Maida’s risk of a Deep Vein ThrombosisSNYSStudent to add answer hereQ6Review Maida’s Medical Orders. What has the Medical Officer prescribed to reduce the risk of a Venous ThromboembolismSNYSStudent to add answer hereQ7State 1 (one) nursing intervention that assists in reducing Maida’s risk of a Pulmonary EmbolismSNYSStudent to add answer hereQ8State 2 (two) potential complications of Maida’s Immobility preoperatively.SNYSStudent to add answer hereQ9State who is responsible for consenting Maida for her surgical procedure.Student to add answer hereQ10Maida has refused to have the S/C Clexane 80mg administered. Outline how you would document this in her progress notes.SNYSStudent to add answer hereQ11Outline what a Malnutrition Universal Screening Tool (MUST) is.SNYSStudent to add answer hereQ12Explain the PQRST Pain Assessment Tool.SNYSStudent to add answer hereQ13Describe how Maida’s age increases her risk of morbidity.SNYSStudent to add answer hereQ14State two (2) pieces of equipment you will need to monitor Maida post-operatively.SNYSStudent to add answer hereQ15Discuss how you would prioritise Maida’s care on the Early shift day 1 post operatively.SNYSStudent to add answer hereQ16Discuss what you would do if you found Maida confused and disoriented and she is refusing to wait for you to assist her to get out of bed?SNYSStudent to add answer hereQ17State two (2) ways you would ensure Maida was able to rest and sleep during her hospital admission?SNYSStudent to add answer hereQ18State one rationale for completing a Falls risk assessment on Maida.SNYSStudent to add answer hereQ19State one rationale for completing a Skin assessment on Maida.SNYSStudent to add answer hereQ20Describe 2 (two) nursing interventions that reduce the risk of Maida’s skin from potentially breaking down.SNYSStudent to add answer hereQ21How does immobility increase Maida’s morbidity?SNYSStudent to add answer hereQ22State two (2) complications that Deep Breathing and coughing exercises help reduce.SNYSStudent to add answer hereQ23Outline one (1) nursing intervention that would assist with Maida’s Physical comfort preoperatively.SNYSStudent to add answer here Q24Using the ISBAR (SA students) / ISOBAR (WA Students) acronym, write out the handover you would provide to the Night Duty Nurse at 2100. (Hint you are the EN who has worked on the Late Shift and have taken the handover from the ED RN when Maida arrived on your ward at 2030.)SNYSStudent to add answer hereISBAR (SA Students) IdentificationSituationBackgroundAssessmentRecommendationISOBAR (WA Students) IdentificationSituationObservationsBackgroundAssessmentRecommendation Part B –Maida’s Nursing Care Plan- Maida has been to Theatre and has had her L) # NOF surgically repaired. She has spent 2 and half hours in Recovery and has now returned to the ward and you have been allocated to care for her. Complete Maida’s care plan for her post-operative care. This question requires you to complete Maida’s care plan. The actual/potential problems have been prefilled. You are required to complete one (1) Nursing Diagnosis, one (1) Nursing Intervention, one (1)Rationale for each nursing intervention and one (1) evaluation for each nursing intervention (how you would evaluate the nursing intervention was effective). Q1Complete Maida’s care plan section for: Nursing Interventions, Rationale and EvaluationActual Potential Problem IdentifiedNursing Diagnosis Include one (1) Nursing DiagnosisNursing InterventionInclude one (1) Nursing InterventionRationale Include one (1)Rationale for each nursing interventionEvaluation Include one (1)evaluation for each nursing intervention1a)ADLS, personal care, dressing groomingQ1Complete Maida’s care plan section for: Nursing Interventions, Rationale and EvaluationActual Potential Problem IdentifiedNursing Diagnosis Include one (1) Nursing DiagnosisNursing InterventionsInclude one (1) Nursing InterventionRationale Include one (1)Rationale for each nursing interventionEvaluation Include one (1)evaluation for each nursing intervention1b oral hygiene1c)Skin integrityQ1Complete Maida’s care plan section for: Nursing Interventions, Rationale and EvaluationActual Potential Problem IdentifiedNursing Diagnosis Include one (1) Nursing DiagnosisNursing InterventionsInclude one (1) Nursing InterventionRationale Include one (1)Rationale for each nursing interventionEvaluation Include one (1)evaluation for each nursing intervention1d)Falls risk1e)Deep Breathing and Coughing exercises Part C – Evaluate outcomes of Maida’s care Short answer knowledge-based case study questions Performance criteriaRecord of resultsQ1How would you ensure Maida was safe to mobilise post-operatively around her room?SNYSStudent to add answer hereQ2What is a Multidisciplinary Team?SNYSStudent to add answer hereQ3Outline Two (2) Multidisciplinary Team members who would be involved in Maida’s care.SNYSStudent to add answer hereQ4As you have been caring for Maida every day since her admission the Shift Coordinator Mary, (RN) asks you to attend the weekly Multidisciplinary Case Meeting. Mary asks you to handover and outline Maida’s progress and discuss her discharge plan. Outline what your role is regarding recording and reporting what is discussed in the Multidisciplinary Case Meeting?SNYSStudent to add answer hereQ5You are caring for Maida Day 2 post operatively and you identify that Maida’s care plan needs to be updated and care changed. Outline who you would report this to and why.SNYSStudent to add answer hereQ6Following on from question five (5), You have updated Maida’s care plan to reflect the changes to her care. State where you would document these changes in Maida’s care.SNYSStudent to add answer hereQ7Outline how you would promote Maida’s independence during her hospital stay?SNYSStudent to add answer hereQ8Discuss how an increased Length of Stay in hospital may exacerbate Maida’s pre-existing condition of Depression?SNYSStudent to add answer hereQ9Outline how you would ensure Maida’s privacy and dignity was maintained when she has a shower in hospital?SNYSStudent to add answer hereQ10State two (2) post-operative complications that would increase Maida’s length of stay in hospital.SNYSStudent to add answer here Part D – Practical skills You are required to read the case study background information on Maida Longbridge and use this information to demonstrate knowledge and rationale as to why the following skills would be important nursing interventions when caring for Maida. The practical skills component of this assessment will take place in the clinical skills lab at a time advised by your educator. The practical skills you will be assessed on will be conducted against the competency checklists provided in the textbook: Koutoukidis, G. and Stainton, K (2017). Essential enrolled nursing skills for person-centred care. 7th Ed. Sydney: Elsevier Australia The three (3) skills to be demonstrated and assessed as part of this assessment are as follows: Clinical Skill 19.4 Assessment of Venous Thromboembolism Assessment (page 40-41)Clinical Skill 19.5 Assessment of Nutrition Assessment/ Weight, Height and BMI (page 45 -46)Clinical Skill 25.3 Assessment of Incentive Spirometry (page 214-215) Assessment Evidence Checklist The assessment evidence checklist is a record of your assessment activity outcome. Once you have submitted all Four (4) parts of this assessment into OpenSpace, your educator will provide feedback and comments on this checklist and will provide a copy of this into OpenSpace once your assessment submission has been marked.You have two attempts to complete the assessment. If you need to re-attempt the assessment task your educator will give you clear and direct feedback with revised submission dates if required. Student has completed and achieved all criteria for the assessment 35821/05 Implement, monitor and evaluate nursing care plans, including providing all evidence which includes:Attempt:SatisfactoryNot Yet SatisfactoryPart A – Short answer knowledge-based case study questionsStudent has completed all Twenty-Four (24) questions. Academic Integrity/ Plagiarism All the student’s work is original, sourced and referenced where appropriate. Part B – Maida’s nursing care planStudent has completed all five (5) actual/potential problems of the Nursing Care Plan including. one (1) Nursing Diagnosis, one (1) Nursing Intervention, one (1)Rationale for each nursing intervention one (1) evaluation for each nursing interventionAcademic Integrity/ Plagiarism All the student’s work is original, sourced and referenced where appropriate. Part C – Short answer knowledge-based case study questionsStudent has completed all Ten (10) questions. Academic Integrity/ Plagiarism All the student’s work is original, sourced and referenced where appropriate. Part D – Practical skillsStudent has uploaded the following clinical skills/practical skills task into OpenSpace. The three (3) skills to be demonstrated as part of this assessment are as follows: Clinical Skill 19.4 Assessment of Venous Thromboembolism Assessment Clinical Skill 19.5 Assessment of Nutrition Assessment/ Weight, Height and BMI Clinical Skill 25.3 Assessment of Incentive SpirometryEducator’s commentsIf work submitted by the student was found ‘Not Yet Satisfactory’ advise what action is required and due date for resubmission: Resubmission requiredDate for resubmission      OtherEducator Name:       Date       All terms mentioned in this text that are known to be trademarks or service marks have been appropriately capitalised. Use of a term in this text should not be regarded as affecting the validity of any trademark or service mark. © YourLife Health & Learning Inc, 2020. All rights reserved. No part of the material protected by this copyright may be reproduced or utilised in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

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