HLTENN003 - Perform Clinical Assessment & Contribute to Planning Nursing Care - Mrs Anh Case Study - Nursing Assignment Help

Assignment Task

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 Australia
• Buddist & speaks Vietnamese & English
• Lives 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, Asthma
• Depression
• Lactose intolerant
• Hearing aid left ear
• Bi-focal glasses (broken in fall)
• Upper dental partial plate
• Medication – Amlodipine, Metformin, Salbutomole.

Doctor’s 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 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
1. Using the headings below explain how you would prepare for Mrs Thuy’s arrival to the ward.
a) Preparation of room:

b) List 4 piece of equipment required for a patient assessment:

c) List four (4) types of forms and or risk assessment tools that will be required as part of Mrs Thuy’s admission:

2. Identify 4 components of correct nursing documentation?

3. Clinical Handover is an important part of continuity of patient care and safety. Nurses use the tool ISBAR when giving clinical handover.
a) What information would you include when doing a verbal clinical handover for Mrs Thuy to your Registered Nurse? Please use the ISBAR format.

PART 2
Answer the following short answer questions in relation to the scenario and assessment documents.

1. Explain 3 strategies to ensure Mrs Thuy privacy and confidentiality using a culturally appropriate approach during her hospital stay.

2. When should the discharge plan for Mrs Thuy begin? List 4 things that are required for a patient’s successful discharge.

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