Student NameStudent NumberUnit Code/s & Name/sAssessment and Care Planning HLTENN003 Perform clinical assessment and contribute to planning nursing care HLTENN004 Implement, monitor and evaluate nursing care plansAssessment TypeWrittenAssessment NameWritten Case StudyAssessment Task No.AT2Assessment Due DateDate submittedAssessor NameStudent Declaration: I declare that this assessment is my own work. Any ideas and comments made by other people have been acknowledged as references. I understand that if this statement is found to be false, it will be regarded as misconduct and will be subject to disciplinary action as outlined in the TAFE Queensland Student Rules. I understand that by emailing or submitting this assessment electronically, I agree to this Declaration in lieu of a written signature.Student SignatureDatePRIVACY DISCLAIMER: TAFE Queensland is collecting your personal information for assessment purposes. The information will only be accessed by authorised employees of TAFE Queensland. Some of this information may be given to the Australian Skills Quality Authority (ASQA) or its successor and/or TAFE Queensland for audit and/or reporting purposes. Your information will not be given to any other person or agency unless you have given us written permission or we are required by law. Instructions to StudentGeneral Instructions: This assessment is an open-book assessment that consists of short answer questions related to the workplace simulated scenarios on the following pages. Students are required to attempt all questions in the assessment to support a successful result. Students are expected to complete unit content and personal study to assist in completing the assessment successfully. Students are to adhere to the TAFE Queensland Student Rules and Policies for assessment; for more information, refer to https://tafeqld.edu.au/about-us/policy-and-governance/policies-and-procedures/student-rules-and-policies/index.html Students are reminded to submit their own workings and that collusion and plagiarism are recognised as Academic Misconduct. If you have any questions about this please email your teacher. Please review the marking criteria for this assessment to ensure you are providing the required information in your answers.Information / Materials provided: This is an open book assessment.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. You must complete this assessment task by the due date provided or you may receive an unsatisfactory (U) result. If you are unable to meet a scheduled assessment due date, you must notify your teacher at least 48 hours prior to the due date to request an extension. All requests for extensions must be in writing on a request for extension form. Extensions are granted in exceptional circumstances only and must be supported by appropriate documentary evidence. For more information, refer to the TAFE Queensland Student Rules and Policies: https://tafeqld.edu.au/about-us/policy-and-governance/policies-and-procedures/student-rules-and-policies/index.htmlSubmission detailsInsert your details on page 1 and sign the Student Declaration – This will confirm you are submitting your own work. Include this template with your submission. Your due date for this assessment can be found in the unit study guide.Academic and research misconduct APA 6th 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 TAFE Queensland Student Rules and Policies: https://tafeqld.edu.au/about-us/policy-and-governance/policies-and-procedures/student-rules-and-policies/index.htmlMethod of submission Assessment to be submitted via TAFE Queensland Learning Management System: Connect url: https://connect.tafeqld.edu.au/d2l/login Username; 9 digit student number For Password: Reset password go to https://passwordreset.tafeqld.edu.au/default.aspxInstructions for the AssessorStudents 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. The student must demonstrate key skills and knowledge identified in the marking criteria for this assessment task. Assessors are to refer to the Benchmark Answers to ensure objectivity and consistencyNote to StudentAn overview of all Assessment Tasks relevant to this unit is located in the Unit Study Guide. Case Study – Mrs Anh Thuy Mrs Anh Thuy is a 43 year old lady admitted following an incidence of blurred vision, numbness down the right side and a sharp pain in her head. A neighbour found her on the ground unable to move or speak. She has been diagnosed as having an ischaemic cerebro-vascular accident. She was immediately commenced on anti-coagulant therapy. Family history – Born to Vietnamese parents in AustraliaBuddist & speaks Vietnamese & EnglishLives with husband & 2 children, Grace 4 years old & Ty 13 years old. Also father who is a frail 82 year old. Medical history – Hypertension, Type 2 Diabetes, AsthmaDepressionLactose intolerantHearing aid left earBi-focal glasses (broken in fall)Upper dental partial plateMedication – Amlodipine, Metformin, Salbutomole. Admission observations – BP 170/100 PR 90 regular RR 24 To 36.4 SpO2 98% on room air BGL 7.4 mmol Weight 71 kg Height 152 cmGCS (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 & shoulderLarge haematoma right hip5cm skin tear right elbowDysphasiaDysphagiaRight sided facial droop Doctor’s orders and interventions– Rest in bed (RIB)2nd hourly Neurological observationsNil by mouth (NBM) until Speech Therapist reviewPhysiotherapist reviewFull assistance with hygieneIDC insituIntravenous Therapy via cannula in left forearm Discharge Information – Mrs Thuy 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. PART 1 Using the headings below explain how you would prepare for Mrs Thuy’s arrival to the ward.Preparation of room: List 4 piece of equipment required for a patient assessment: List four (4) types of forms and or risk assessment tools that will be required as part of Mrs Thuy’s admission: Identify 4 components of correct nursing documentation? Clinical Handover is an important part of continuity of patient care and safety. Nurses use the tool ISBAR when giving clinical handover.What information would you include when doing a verbal clinical handover for Mrs Thuy to your Registered Nurse? Please use the ISBAR format. ISBAR PART 2 Answer the following short answer questions in relation to the scenario and assessment documents. Explain 3 strategies to ensure Mrs Thuy privacy and confidentiality using a culturally appropriate approach during her hospital stay. When should the discharge plan for Mrs Thuy begin? List 4 things that are required for a patient’s successful discharge. Consider Mrs Thuy’s discharge home and what might she require assistance with at home. Complete the following table by identifying three (3) issues she may require assistance with at home and the community services that could be arranged assist with her transition home. Requires assistance with…Support /Resource service Mrs Thuy has had a cerebro-vascular accident (CVA).Explain a CVA including where it occurs and what causes it. Identify four (4) signs and four (4) symptoms of a CVA. Symptoms Signs Patients who have had a CVA can be hospitalised by a long period of time. Identify four (4) risks of long term hospitalisation on patients. Mrs Thuy has had her IDC removed but now has urinary incontinence. Define Urinary and faecal incontinence and give three (3) examples of incontinence aids for both men and women. Definition Incontinence aids What interventions can be done to help patients with incontinence? Provide four (4) examples interventions. List two (2) factors each that promote and impede on comfort, sleep and rest. Factors that impedeFactors that promoteComfortSleep/rest Review Mrs Thuy’s vital signs and clinical data on admission. Answer the following questions in relation to this assessment data.Blood pressure 170/100 What is the normal range for Systolic and Diastolic blood pressure in an Adult? Is Mrs Thuy’s blood pressure reading within normal range? What is the correct terminology of this condition? What would you do as a result of this reading? Pulse rate 90 regular What is the normal range for adult pulse rate? Is Mrs Thuy’s pulse rate within normal range? What would you do as a result of this data? Respiratory rate 24 What is the normal range for adult respiratory rate? Is Mrs Thuy’s respiratory rate within normal range? What is the correct terminology of this condition? What would you do as a result of this data? Temperature 36.4 What is the normal range for adult temperature? Is Mrs Thuy’s temperature within normal range? What would you do as a result of this data? Oxygen saturation (SpO2) 98% on room air What is the normal range for oxygen saturation? Is Mrs Thuy’s SpO2 within normal range? What would you do as a result of this data? BGL 7.4 mmol What is the normal range for blood glucose levels? Is Mrs Thuy’s BGL within normal range? What would you do as a result of this data? GCS = 14, PERL Is this normal? What would you do as a result of this data? Using the following formula calculate Mrs Thuy’s BMI:- BMI = kg/m2 BMI = (please enter your calculation from the nursing assessment form) Is this normal? Owing to the dysphasia suffered following the CVA Mrs Thuy is having difficulties communicating. Outline three (3) strategies that could be used to assist Mrs Thuy with her communication. Mrs Thuy identifies strongly with her Vietnamese culture. Outline two (2) strategies you could implement to support her cultural, spiritual and religious needs. Where would you document these? Mr Thuy is worried about his wife and the impact hospitalisation has had on the family. He is very distressed about the current situation. Identify three (3) potential causes of Mr Thuy’s distress and strategies that could be implemented to support Mr Thuy during this stressful time. StressorsStrategies to support Mr Thuy Part of the nurse’s role is to assess how Mrs Thuy is coping with the changes in her functional status following her CVA. Describe three (3) behaviours that Mrs Thuy might display if she was not adapting to the changes experienced. The RN has identified a number of nursing diagnosis’ for Mrs Thuy. Develop a nursing care plan using the following nursing diagnosis. Provide 2 interventions and a rational for each intervention Care PlanNursing diagnosis (NANDA)Risk of impaired skin integrity related to immobility resulting from CVAAssessment (subjective and objective data)Plan (goal, expected outcome, what do you hope to achieve)Implementation (nursing interventions)Rationale (reason why)126.96.36.199.Evaluation (did the plan of care work, how will you know) Care PlanNursing diagnosis (NANDA)Risk of falls related to immobility resulting from CVAAssessment (subjective and objective data)Plan (goal, expected outcome, what do you hope to achieve)Implementation (nursing interventions)Rationale (reason why)188.8.131.52.Evaluation (did the plan of care work, how will you know) Care PlanNursing diagnosis (NANDA)Risk for aspiration related to impaired swallowing resulting from CVAAssessment (client has/has not, data)Plan (goal, expected outcome, what do you hope to achieve)Implementation (nursing interventions)Rationale (reason why)184.108.40.206.Evaluation (did the plan of care work, how will you know) Care PlanNursing diagnosis (NANDA)Risk for impaired social function related to depressed mood and impact of major health event (CVA)Assessment (client has/has not, data)Plan (goal, expected outcome, what do you hope to achieve)Implementation (nursing interventions)Rationale (reason why)220.127.116.11.Evaluation (did the plan of care work, how will you know) The admission process is now complete, you give Mrs Thuy a sponge in bed. Describe three (3) observations or assessments you would make while performing this procedure. Mrs Thuy has had her IDC removed. Mrs Thuy is complaining of burning and stinging when she passes urine, a urinalysis has been performed with the following results: ColourOdorGluBilKetSGBlopHProUroNitLeuCloudyOffensiveNegNegNeg1.025Neg8.0NegNormal+ve++ Based on this information, what is your assessment of the situation? Why? In your answer identify which of these results are outside normal range. Describe two (2) nursing interventions you could implement (do not include administering antibiotics in your answer) to improve this situation. Mrs Thuy presses her call bell and tells you she feels “dizzy and has the shakes”, you observe that she is cold and clammy and notice that she has not eaten any of her breakfast as she was unable to reach her breakfast tray. Using the information in Mrs Thuy’s medical history, knowledge gained in the assessment process and your knowledge of anatomy and physiology, what would you suspect was the problem? Outline the steps you would take to manage this situation as a Student Enrolled Nurse. What is the problem? List three (3) nursing interventions to manage the presenting problem. Mrs Thuy has a history of hypertension. List 4 environmental factors and genetics that can influence the development of this condition. Identify which stage of Erikson’s stages of psychosocial development Mrs Thuy fits in and identify 2 activities related to this stage. Identify 2 other stages Erikson’s stages of psychosocial development and provide at two (2) activities per stage. StagesMajor activities Identify three (3) gender specific health issues that Mr & Mrs Thuy might experience. Mrs Thuy confides in you that she and her husband have been trying to conceive another child prior to her CVA. Discuss the impact infertility may have on the couple. Mr Thuy is new to the role of caring for young children as this has always been managed by his wife. Describe the role of play in child development. Mr Thuy’s son has been exhibiting challenging behaviours since his mother’s admission. Outline the major developmental stages and common health issues of adolescence.Major development stages. Common health issues of adolescence. Complete the following table in relation to growth and development to help Mr Thuy understand the stages of childhood. StagePhysical growthPsychosocial developmentCognitive developmentMotor development0–12 monthsGains weight, body grows in lengthNot required for this age group.Smiles & laughs, looks towards sounds, repeats actions, imitatesMoves whole body, turns head when cheek touched, rolls from side to side, able to grasp objects Crawling, takes weight on feetToddlerAcceptance of the cycle of life, from integration to disintegrationPre-schoolHumour, empathy, resilienceSchool agedHumility, acceptance of the course of one’s life and unfulfilled hopes. Mr Thuy is providing ADL support to his 82 year old father-in-law, Mrs Thuy and his two children. Complete the following table to look at health needs across the lifespan. Provide two (2) extra examples of the cares that can be carried out for each activity of daily living Activities of daily living4 year oldMrs Thuy(on discharge)82 year oldPersonal hygiene/ groomingAssistance with hygiene needs as required. 1.2.Shower chair 18.104.22.168.Eating & drinkingEncourage oral fluids. 1.2.Diabetic diet Modified diet (thickened fluids, soft diet) 1.2.Assistance with food preparation. 1.2.Mobility1.2.Mobility aids Non-slip shoes 22.214.171.124.SafetyCorrect food texture 1.2.Use of assistive devices including mobility aids, plate guards, non-slip mats/shoes, handrails 1.2.Remove trip hazards /clear clutter 1.2.Toileting126.96.36.199.1.2. Mr Thuy feels he needs physical & emotional support. What advice would you give him?
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