HLTENN037 - Perform Clinical Assessment And Contribute to Planning Nursing Care

Assignment Task

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. 

Question

1. Provide an answer for each of the questions below in relation to Mrs Hui.

• Explain how you would prepare the hospital room for Mrs Hui’s admission to the ward.
• List 4 pieces of equipment you would need to conduct an assessment on Mrs Hui’s 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?

2. Using the ISBAR format, what information would you include when doing a verbal bedside clinical handover for Mrs Hui?

3. 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.

4. 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.

5. Identify which of these results are outside normal range and what might these abnormalities indicate?

6. Provide four (4) nursing care interventions you can do to promote continence and manage incontinence for Mrs Hui.

7. Provide three (3) examples of urinary and faecal incontinence aids (other than an Indwelling catheter) for both men and women.

8. Provide a nursing action for each personal care listed in the table.

9. Outline three (3) reasons why it is important for the nurse to ensure Mrs Hui’s hygiene and grooming needs are met

10. List two (2) factors that impede sleep, comfort, and rest and two (2) factors that promote comfort, sleep, and rest.

11. 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.

12. State the documentation required to assist in the prevention of falls for Mrs Hui.

13. Outline two (2) actions to promote and encourage active and passive exercises for Mrs Hui while on bed rest.

14. Outline two (2) actions to promote and encourage effective breathing for Mrs Hui while on bed rest.

15. Identify two (2) recommendations to Mr Hui in regards to physical activity requirements for 5- and 13-year-old children.

16. Identify two (2) recommendations to Mr Hui in regards to physical activity requirements for his 82-year-old father-in-law.

17. 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.

18. 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.

19. 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 Hui’s 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 Olivia’s 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.

21. Using the ARC guidelines for DRSABCD what you do.

22. 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.

23. 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?

24. Identify three (3) nursing actions you can do to help reassure and settle Cheryl.

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