Highlights
Task Instructions
To complete Assessment 1, Part B, provide your responses to the questions on the Assessment Response Template below. Your responses must be typed into the spaces provided beneath each question, and the whole document and associated charts must be submitted to Blackboard as your response to Part B. Assessment 1, Part B, should build on your responses to Assessment 1, Part A, by demonstrating your knowledge of the client’s related medical history, Nursing Care Plan recommendations and current vital signs.
Question 1
On Sunday at 13:42hrs, you are about to leave to have your lunch break when Mr McFarlane’s wife calls you from the corridor and states “Nurse! My husband does not look well and something is wrong with him. Please
can you come and have a look at him?” On entry to Mr McFarlane’s room, you notice the following:
Discuss your nursing actions and rationales for your decisions, taking into account policies and procedures and scope of practice as an Enrolled Nurse (EN).
Question 2
Based on the initial handover you received for Mr McFarlane and, taking into account his recent clinical deterioration, consider how best to update the plan of care for Mr McFarlane. Use the template below to outline the anticipated care for Mr McFarlane taking into consideration his past medical history and recent events. Ensure that you remain within your EN Scope of Practice and take into account policies and procedures. This requires you to:
-Outline two (2) new nursing diagnoses or risk factors associated with Mr McFarlane’s current health presentations (these nursing diagnoses or risk factors cannot be the same ones used in Assessment 1, Part A)
-List and justify at least one (1) nursing intervention(s) that could be instigated for each diagnosis.
-Specify at least one (1) member of the multidisciplinary team that may be able to support your suggested interventions.
Question 3: Nursing Documentation
At the end of your shift you need to complete nursing documentation to record the care you provided to Mr McFarlane. Using either a Head to Toe Assessment Entry or Systems Entry, document the care provided to Mr McFarlane below.
Consider the following:
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