ASSESSMENT 1 Response Template
Student Name
answer here...
Date
answer here...
Course
HLT54115 Diploma of Nursing
Subject Title
Assessing physical health status
Unit of Competency
HLTAAP002 Confirm physical health
HLTENN003 Perform clinical assessment and contribute to planning nursing care
Performance Criteria, Knowledge and Performance Evidence Assessed
PC:
HLTAAP002: 1.1, 1.2, 1.3, 1.4, 2.1, 2.2, 2.3, 3.1, 3.2, 3.3, 3.4
HLTENN003: 1.1, 1.2, 1.3, 1.6, 1,7, 2.1, 2.2, 2.1, 2.3, 2.4, 3.1, 4.1
PE:
HLTAAP002: 1
HLTENN003: 1, 2
KE:
HLTAAP002: 1, 2a, 2c, 3a, 3b, 3c, 3d, 3e, 3f, 3g, 3h, 3i, 3j, 3k, 3l, 3m, 4a, 4b, 5, 6, 11a, 11b
HLTENN003: 1, 14, 20
Title of Assessment Task
Assessment 1
Part 1: Short Answer Questions
For this assessment, you must watch the case study scenario and respond to the questions below. Some of the information you need will be in the video and some will be in this overview, while the majority will come from what you have covered in modules 1-3.
Patient Details
· George McFarlane, male, born in Australia, age 53 years.
· Address: 62 Koala Avenue, Belle Hill 2023 NSW
· Medicare Number XXXXXXXXXX/1
· Private Health: HCA hospital only
· GP Dr. Wing Lo Chiang
Medical History
· George weighs 118 kg and his height is 180cm.
· He is a cu
ent smoker and smokes 15 cigarettes a day which he has done for 30 years.
· He has type 2 diabetes (2 years) and osteoarthritis in his Left knee. He lives a sedentary life style.
· Takes BGL daily.
· Sees Dr every 6 months.
· Allergic to Penicillin
Social History
· Occupation long haul truck driver.
· Religion Anglican but does not go to church.
· Has a 26-year-old son from a first ma
iage who has depression and uses illicit drugs, visits occasionally.
· Has a stepson, Jason aged 17 from his second ma
iage to Yu Yan whom he ma
ied 5 years ago and with whom he lives.
· Yu Yan is of Chinese heritage and speaks English well.
· George and Yu Yan are parents to 3-year-old twins from his cu
ent ma
iage. One twin has a developmental disorder.
· George is away from home a lot on the road travelling for work to pay the bills.
· George is often isolated from his family and friends, due to his occupation. He telephones his wife daily when away.
· George often watches TV and drinks a few beers a night to cope with stress.
Context
George has come into hospital today as his BGL is higher than normal at 15mmols. He has a headache, feels lethargic, is passing an increased volume of urine and has increased thirst. He is also short of
eath when walking and exercising. On admission, the nurse takes a set of vital signs and completes the admission form. A urinalysis is also taken.
TASK
Assessment Criteria
Question 1
In relation to the case study video scenario you have just watched, and the patient history you have, please complete the admission form provided. You must complete every section that is blank. Some sections are prefilled for you.
ADMISSION NOTES
(provide an overview of the patient’s situation)
answer here...
NAME:
answer here...
ADDRESS:
answer here...
GP:
answer here...
MEDICARE NO.
answer here...
DATE:
answer here...
AGE ON ADMISSION:
answer here...
GENDER:
answer here...
RELIGION:
answer here...
ETHNICITY:
answer here...
ALLERGIES:
Penicillin
LIFESTYLE PATTERNS:
answer here...
COPING MECHANISMS:
answer here...
SOCIAL:
Watches TV drinks a few beers each night.
Lives with his wife and children.
CURRENT HEALTH PRACTICES / NEEDS:
Takes BGL daily. Sees Dr 6 monthly
ADL ASSESSMENT:
DIET: answer here...
URINARY AND BOWEL PATTERNS: answer here...
MOBILISATION: answer here...
HYGIENE: answer here...
FAMILY CONCERNS AND NEEDS RE: CLIENT:
answer here...
ADMISSION OBSERVATIONS:
T37 answer here...
P: 110bpm answer here...
RR: 26 answer here...
BP: 170/90 answer here...
SaO2: 97% answer here...
HEIGHT: answer here...
WEIGHT: answer here...
BMI: answer here...
CURRENT MEDICATIONS:
answer here...
NURSING NOTES:
Below, you should summarise the points from the video and provide some additional information on the client’s history, and some notes about your assessment, and an admission plan (Sign off with name, signature and delegation at the end of the notes).
New client, Mr George McFarlane admitted to ward at 1000.
History: (Provide a sentence or two about the client’s history and cu
ent situation – point form ok).
Assessment: (Provide some points about what was discovered during the health assessment and discussion. Some are filled out already.)
· answer here...
· Observations, as recorded in admission observations above.
· answer here...
· Reported to the RN.
· answer here...
Admission Plan: (Provide some points about the actions you recommend taking from this point. Some are filled out already.)
· answer here...
· Provide regular analgesia as charted
· answer here...
· A
ange for the doctor to review Mr McFarlane.
· answer here...
Name: ___________________
Signature _______________
TASK
Assessment Criteria
Question 2
The nurse has taken Mr. McFarlane’s blood pressure and it is 170/90mmHg. In 50 words, list the parameters for normal blood pressure and the range for hypertension. Include in your answer whether Mr. McFarlane’s blood pressure is within normal range.
Response: answer here...
TASK
Assessment Criteria
Question 3
As an Enrolled Nurse (EN), explain in 20 words who you should report your findings to and why, if a client’s measurements are displaying unusual levels, or you are concerned about the results you have received?
Response: answer here...
TASK
Assessment Criteria
Question 4
In 50-75 words, identify your scope of practice as an EN in this situation, and list your roles and responsibilities compared to that of a Registered Nurse (RN).
Response: answer here...
TASK
Assessment Criteria
Question 5
Mr. McFarlane's other observations are noted below. In 30 words, indicate the normal ranges for temperature, pulse and respirations and state whether Mr. McFarlane’s observations are within normal range.
Cu
ent observations:
· Respirations at 26
eaths per minute.
· Temperature 37C
· Pulse 110 beats per minute (bpm).
· SpO2 97% on room air.
Response: answer here...
TASK
Assessment Criteria
Question 6
Mr. McFarlane has provided a urine sample. The urine sample is clear. When attending a urinalysis, you note the sg is 1005 and the ph. is 6 ketones + and glucose ++. In 20-30 words, identify the abnormal results and specify what condition Mr. McFarlane's abnormal results may relate to.
Response: answer here...
TASK
Assessment Criteria
Question 7
Mr. McFarlane has a significant medical and social history. Name three (3) factors (actual or potential) that could have contributed to his medical issues.
Response: answer here...
TASK
Assessment Criteria
Question 8
Name three (3) health care professionals found in a hospital setting that you might be able to refer Mr. McFarlane to for assistance with his health variations. For each professional, in 20 words, state their role and how they could contribute to Mr. McFarlane wellness.
Response: answer here...
TASK
Assessment Criteria
Question 9
Below are the health conditions Mr. McFarlane has. For each condition, name the body system, which relates to it and specify what that system is responsible for doing.
For example, kidney stones relate to the Urinary system, which eliminates waste from the body, regulates blood volume and blood pressure, controls levels of electrolytes and metabolites, and regulates blood pH.
· High blood pressure
· Type 2 diabetes
· Obesity
· Shortness of
eath on exertion
· Osteoarthritis left knee
Response: answer here...
TASK
Assessment Criteria
Question 10
In 100 words, discuss the pathophysiology of Type 2 Diabetes in relation to the pathophysiology of the system involved. In your response, specify the body system affected and what has happened to the cells to cause this condition.
Response: answer here...
TASK
Assessment Criteria
Question 11
Mr. MacFarlane has been taking regular oral pain medication for some time (tablets for the osteoarthritis in his left knee). With regard to Mr. McFarlane’s situation and the way he takes this medication, specify a factor that might affect therapeutic levels, and explain in 100 words why this might happen. In your response, consider basic pharmacology, contraindications and pharmacokinetics.
Response: answer here...
TASK
Assessment Criteria
Question 12
Mr. McFarlane’s wife Yu Yan is originally from China. If Mr. McFarlane were to become unresponsive you would need to communicate with her. In 75 words, explain a strategy you could use when talking to Mrs. McFarlane that would demonstrate appropriate cultural respect and understanding during your interaction.
Response: answer here...
TASK
Assessment Criteria
Question 13
Mr. McFarlane, has been reviewed by the Dr. and a number of other relevant health professionals. Mr. McFarlane has all discharge planning and refe
als complete prior to discharge. The Hospital Dr. has advised Mr. McFarlane to follow up with his GP in one week. Now, Mr McFarlane needs to be discharged from care, and the appropriate records need to be kept. Complete the following discharge summary by indicating which option is co
ect in the spaces provided.
In each box below, select the co
ect option.
Discharge planning needs:
Living a
angements:
Discharge transport a
angements required:
Does the patient have any concerns related to discharge?
Does the patient require any services for showering, wound dressings, medication management etc?
Does the patient already have community services?
Does the patient require a medical certificate?
Was discharge information provided and recorded in progress notes?
Should follow up appointments made and given to the client?
Should patient have own medications, x-rays and valuables returned?
Should invasive devices be removed?
Should a medical discharge summary be completed and given to client?
TASK
Assessment Criteria
Question 14
Below is a table listing a range of common diseases, disorders and their symptoms. Using the list of body systems below, specify which