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HLTENN003 Perform Clinical Assessment And Contribute To Planning Nursing Care1

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  • Course Code: HLTENN003
  • University: Australia Institute Of Business And Technology
  • Country: Australia

Question:

Nursing assessment is the first stage of the nursing process. State four reasons why a nursing history is performed on admission?

Explain why it is important to involve your client and/or their family whilst conducting nursing assessments?

What is meant by holistic care?

List 4 points relating to the documentation guidelines that you must comply with when recording any information.

You are asked to take vital signs on a client. State 4 indications to complete vital signs

Match the appropriate term with the correct temperature range

Hyperthermic

 

36.2 -37.5 0C

Afebrile

 

35.0  36.0 0C

Hypothermic

 

 

37.5 – 39.0 0C

It is recommended to take a confused person’s temperature via the oral route

When taking a client’s pulse, what 3 characteristics must be assessed?

When taking a client’s respirations, what 3 characteristics must be assessed?

 

Answer:

Question 1

To recognize current and future patient care requirements

Involves the recognition of normal against abnormal body physiology of the patient

Provides a chance to form an interpersonal relationship with the patient, hence able to discuss health care concerns with the nurse

Identifying the patient's strengths provides the nurse information about the abilities, skills, and behaviours the patient can use during treatment and recovery process

Question 2A

Network with the family when developing a care plan

Seek advice on client’s care preferences

Establish current family’s dynamics in decision making

Determine the client’s ability to perform self-care

 

Question 2B

A system of total patient care under consideration of emotional, physical and spiritual desires of a person, the person’s illness response and the effects of the ability in meeting self-care needs

Question 3

Continuity

Safety

Quality

Completeness of the content

Question 4

Body temperature

Blood pressure

Respiratory rate

Heart pulse

Question 5

Hypothermic        37.5 – 39.0 0C

Afebrile                35.0-36.00

Hyperthermic       36.2 -37.5 0C

Question 6

False

The patient will likely bite down on the thermometer

Question 7

Tachycardia

Question 8

Blood sugar

Emotional stress

Physical activity

Adrenal hormone levels

Question 9

Pulse rate

Strength

Rhythm

Question 10

Wrist

Knee

Neck

Groin

Question 11

Bradycardia

Question 12

Rhythm

Depth of ventilation

Breathing rate

Quality of breathing

Question 13

12-60

Question 14

Perfusion during monitoring

Dysfunctional haemoglobin

Interference making readings unavailable

Irregular signals

Question 15

Sp02 of 94% to 99%

Question 16

The maximum arterial pressure during contraction of the left ventricle of the heart

 

Question 17

The lowest arterial blood pressure of a cardiac cycle that is occurring diastole of the heart (Graneheim, Uh & Lundman, 2014).

Question 18

Hypertension

Question 19

Microbes

Question 20

Has a volume of between 750-2000 ml/hour

Mostly pale yellow to deep amber in color

Is odorless

Has a special gravity of 1.003-1.032

Question 21

Dyspnea

Question 22

Hypoglycaemic attack

Question 23

BMI= weight (kilograms)/ Height2 (metres)

Question 24

Obese

Question 25

4.0 to 6.0 mmol/L when fasting to 7.8 mmol two hours after fasting

Question 26

Stages

Conflict to be resolved

Examples

Oral-Sensory (birth to 1 year)

 

Trust vs. mistrust

Feeding

Developing a logic of trust when their handlers provide care, affection and reliability. Without this, mistrust occurs

Musculo-Anal

(1-3 Years)

 

Autonomy vs. shame and doubt

Toilet training

Developing a sense of independence. Success results to autonomy feelings whereas failure brings shame

Locomotor-Genital

(3-5 Years)

 

Initiative vs. guilt

Exploration

Children assert power and control over the environment. Success brings a sense of purpose while lack of it will result to a sense of guilt

Latency

(6 -11 Years)

 

Industry vs. inferiority

School

Young ones should cope with new academic and social demands. Sense of competence yields results whereas failure brings a feeling of inferiority

Adolescence

(12-18 Years)

 

Identity vs. role confusion

Social relationships

Teens begin to develop a logic of personal identity. Success will result to the ability to remain true to yourself, whereas failure results to confusion

Young Adulthood

(19-35 Yrs)

 

Intimacy vs. isolation

 

Relationships

Youths begin to develop intimate and loving relationships. success results to strong relationships and failure leads to isolation

Middle adulthood (40 to 65 yrs)

 

Generativity vs. stagnation

Parenthood and work

Adults foster things that will outlive them. success will lead to feelings of usefulness whereas failure results to miniature envelopment in the world

Maturity (65 to death)

Ego integrity vs. despair

Life reflection

Looking back to life and feeling a sense of contentment. Success results to feelings of wisdom but failure brings regret, despair and unpleasantness

Question 27

A client with diabetes- education and self-management; complications; treatment; monitoring; examination

Client with dyspneic – interview, observation and analysis

Client complaining of pain on micturition – appraisal of factors that influence expression of pain; describing pain and its effect; awareness of barriers that affect pain management

A client who has fallen – screening; considerations

A client who has a plaster cast- cast protection; general instruction to the client

 

Question 28

Total intake =1260

Total output=650

This forms a positive fluid balance

Question 29

Pregnancy testing

Monitor disease progression and reaction to therapy

Routine medical evaluation

Evaluating particular symptoms

Question 30

Bradycardia is a heart rate less than sixty beats a minute.

Tachypnea involves a rapid and faster respiration

Cyanosis refers to the discoloration of the skin and membranes of mucus.

Hypotension is a term referring to low blood pressure.

Question 31

Jaundice refers to the yellowish color of the skin as a result of yellow pigment.

Pallor is the color deficiency of the skin or face which results from illness or shock from emotions.

Turgor refers to the elasticity degree of the skin normally used to determine dehydration level.

Petechial refers to the purple or red spot on the skin resulting from bleeding.

Question 32

Subjective data

Question 33

Holistic assessment is a patient assessment process evaluating the domains i.e. physical, emotional, sexual, financial and cultural demands of a patient.

Question 34

Glasgow coma scale characteristics

  • Reliability
  • Involves construct validity, concurrent validity and predictive validity and
  • Responsiveness

Question 35A

Vomiting and diarrhea assessment strategies.

Determination of whether it is anew onset of diarrhea

The assessment should accurately determine the frequency, duration, symptoms severity and pattern of both the diarrhea and vomiting.

 35B

In an event where a referred patient is allergic to a medication, during admission assessment, I will clearly indicate and record the exact allergic medication and the prescribed stat dose as advised by the medical officer.

Question 36

Discharge plan requirements for a hip replacement patient

Return duration guidelines. This illustrates the frequency and duration in which the patient visits the hospital after replacement of the hip (Orem et al, 2012).

Placement of a dry dressing on the incision on a two days interval

Removal of the hip stitches by the relevant staff who placed them

Consistent use of support for a certain duration of time regardless of comfort in not using them

Consistent placement of a pillow between legs for a 6 weeks period

Showering 4 days after surgery

Avoiding driving in the first 6 weeks of surgery

Taking of narcotic medication as sparingly as possible

 

Question 37A

Steps for 180/105bp measurement

Redoing the measurement experiment after a rest and calming.

A confirmation of medication taking as prescribed previously.

Checking of other conditions that might encourage or worsen the situation.

Improvement on drugs that reduces the blood pressure levels.

Adoption of good living habits that reduces the blood pressure levels.

37B

Causes of high blood pressure

Consumption of drugs

High weights and stress

Question 38

Health education for asthma patient

Strictness and adherence to asthma action plan.

Consistent vaccination against influenza and pneumonia

Identification and avoidance of asthma triggers

Strict monitoring of breathing patterns

Taking of medication as prescribed

Paying attention to increasing quick inhaler use.

Question 39

A relative NO. Zoe has got a different cell composition characteristics, eating habits and living environment from his or her siblings during their childhood stages.

Question 40

 
 

References

Orem, D.E., Taylor, S.G. and Renpenning, K.M., 2012. Nursing concepts of practice.

Graneheim, U.H. and Lundman, B., 2014. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse education today 

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