HLTENN003 Performing Clinical Assessment and Contribute to Planning Nu

Questions

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

2. Part A

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

Part B

What is meant by holistic care?

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

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

5. 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

True

False

Explain your answer

7. ___________________is an abnormal pulse rate greater than 100 beats/minute

8. List 4 factors that affect body temperature

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

10. List the 4 most common sites for taking a pulse measurement.

11. The term for a pulse rate below 60 beats per minute is a ____________________________

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

13. A normal respiratory rate for a child is ________________________breaths per minute.

14. List four factors which may affect pulse oximetry

15. List the normal range of pulse oximetry in a healthy adult.

16. Define systolic blood pressure.

17. Define diastolic blood pressure

18. An elderly client has a blood pressure of 184/102. The client is

19. A client has a urinary tract infection. The client will have an increased level of _________ present in his urine.

20. Outline the normal characteristics of urine.

21. The medical term for shortness of breath is _________________________________

22. A client’s blood glucose level prior to breakfast was 3.1mmol/l, this result is a

23. The correct formula to calculate the body mass index (BMI) is which of the following

24. A client with a BMI of 33.4 is considered to be ____________________________________

25. Blood glucose target ranges may differ depending on age, duration of diabetes and medications. Normal blood glucose levels are between

26. Individual human development is a lifelong continuous process beginning at conception and ending with death and is perceived as involving a series of orderly and predictable changes, which can be classified as physical, social, emotional and intellectual. Complete the following referring to Erikson’s eight stages of development

Stages	Conflict to be resolved	Examples
Oral-Sensory (birth to 1 year)
Musculo-Anal (1-3 Years)
Locomotor-Genital (3-5 Years)
Latency (6 -11 Years)
Adolescence (12-18 Years)
Young Adulthood (19-35 Years)
Middle adulthood (40 to 65 years)
Maturity (65 to death)

27. Outline the specific assessment technique(s) you would use to assess the following clients:

A client who has fallen and is suspected of having a head injury

A client who is dyspneic

A client with diabetes

A client who is complaining of pain on micturition

A person who has a plaster cast on their arm post a recent fracture

28. A fluid balance chart has been ordered for Mr. Leech (UR 0123456789) DOB: 30/06/1949. Complete FBC on the following page below using the following information:

0730 hrs — orange juice 150 mL, milk 140ml	1350 hrs — cup of tea 250 mL, water 100 mL
1030 hrs — cup of tea 180 mL	1430 hrs — voided 250 ml
1115 hrs — water 120 mL	1630 hrs --- vomited 150ml, bile stained fluid
1230 hrs — cup of tea 120 mL jelly 200 mL	1800 hrs --- Bowels open – loose, approximately 100mls
1230 hrs — voided 150 mL urine

The Total intake for the day is
The total output for day is
Is Mr Midler in a positive or negative fluid balance?

29. The urinalysis is another common test routinely taken in almost all acute hospitals as an admission lab screening test. What can a urinalysis reveal?

30. Provide a definition for the following terms

Bradycardia

Tachypnea

Cyanosis

Hypotension

31. Provide a definition for the following terms

Jaundice

Pallor

Turgor

Petechial

32. When completing a nursing assessment, data that is the client’s perception, ideas and sensations is known as ______________________________________________________

33. What is a holistic assessment?

34.What are the 3 characteristics of a Glasgow Coma scale

35. Part A

You are asked to undertake an admission assessment of a 4 year old who is admitted with vomiting and diarrhea. Explain the strategies you would use and why to achieve an accurate assessment

Part B

While undertaking the nursing admission, you note that the General Practitioner has stated in the referral that the child is allergic to a medication, however the Medical Officer has written up a stat dose. What are your actions?

36. You are asked to create a discharge care plan for Mrs Marjorie White who is an 83 year old lady who was admitted for a hip replacement. Outline what is required in the discharge plan.

37. Part A

You have just completed a blood pressure measurement of your client. It was 185/105. List the steps you would take;

Part B

List 2 likely causes of this high reading

38. You are caring for Jess, a 19yr old male who had been recently admitted for asthma.

Explain how you could assist in the health education of Jess prior to discharge.

39. The mother of a 7 month old Zoe asks you if Zoe should reach the same milestones at the same time as her older siblings. What would be an appropriate response?

40. Mrs Joan Smith is a 61 year old lady (UR 333666) was admitted to your ward for day surgery.

Document the following admission observations accurately on the graph observation chart provided.

1400 hrs T – 36.7, P – 100, R – 22, B/P – 140/90.

Weight is 68 kg

Urinalysis reveals a ph of 8.0, positive for leucocytes and SC 1015

No other abnormalities

Answers

1. Nursing history is important to gather information related to medical history, family history, surgical history, medication history and psychological history.

For analysis and diagnosis.

For planning care to the patient.

Implementation of care plan.

Part A:

Accurate information about the patient’s physical and psychological condition can be obtained.

Patient and family members can understand patient’s exact health condition.

Role of patient and family members in decision making in patient’s care can be improved.

Communication between among nurse, patient and family members can be improved.

Part B :

Holistic care is a branch of nursing practice which aims to treat the whole person. For providing holistic care, nurse need to be licenced as holistic care nurse. Holistic nurse should provide nursing care by considering “mind-body-spirit-emotion-environment” of the patient. Holistic nursing is based on the philosophy of living and being in environment of caring, relationship and interconnectedness. Holistic nursing inspire nurse to incorporate elf-care, self-responsibility, spirituality, and reflection in their care practice. Holistic nursing affords and facilitate high level integrated quality nursing service to people with both acute and chronic conditions.

3.Current date, time and nursing heading need to be mentioned in each nursing document.

In each document full signature, printed name and designation need to be mentioned.

Progress note should follow ISBAR philosophy.

Professional nursing language need to be used, generic information should not be mentioned, and duplication should be avoided.

4.Patient should close the mouth while taking temperature of the patient.

Pads of first three figures for gentle palpitation of radial pulse at the inner lateral wrist.

Patient should not know while measuring respiratory rate.

Blood pressure need to be taken in both resting and activity conditions.

Hyperthermic

37.5 – 39.0 ⁰C

36.2 -37.5 ⁰C

Afebrile

Hypothermic

35.0 – 36.0 ⁰C

6. Temperature of confused patient should not be taken by oral route because there is possibility that confused patient can bite the thermometer. Hence, temperature measurement by oral route in confused patient’s is contraindicated.

7. In resting condition pulse rate above 100 beats per minute is abnormal pulse rate.

8. Increase in heart rate can increase body temperature.

Physical exercise can alter normal body temperature. Due to physical exercise, there can be increase in the metabolic rate and increased heat production.

Normal body temperature regulation can be compromised by external environmental conditions. Hot condition can increase body temperature.

Infection can increase body temperature above normal body temperature.

9. Pulse rate, pulse strength and pulse rhythm need to be assessed while taking pulse rate in a patient. Pulse rate gives number of heart beats, pulse strength gives amount of blood forced into artery and pulse rhythm gives information about evenness of the beats.

10. Following are the sites for taking pulse measurement:

Radial pulse at wrist.

Carotid pulse at neck.

Femoral pulse at groin.

Pedal pulse on the foot.

11. Pulse rate below 60 beats per minute is called as bradycardia.

12. While taking respiratory rate in a patient, respiratory rate, respiration depth and pattern of breathing need to be assessed.

13. Normal respiratory rate for children with age 0 – 12 months, 1 – 3 years, 4 – 5 years and 6 – 12 years are 30 – 60, 24 – 40, 22 – 34 and 18 – 30 breaths per minute respectively.

14. Factors affecting pulse oximetry:

Perfusion at the site of monitoring.

Dysfunctional haemoglobin which is also called as dyshemogobinemia.

Interference from external factors which make readings unreliable.

Technique implemented while using pulse oximetry.

15. Normal range of pulse oximetry in healthy adults is 95 – 99 percent.

16. Systolic blood pressure is the pressure exerted by blood on arteries and vessels during heart beating. It is the maximum pressure exerted on the arteries due to contraction.

17. Diastolic blood pressure is defined as the blood pressure which exerted on the walls of arteries in between the heart beats when heart is in relaxed condition. This blood pressure is mainly due to relaxation.

18. A patient who is having blood pressure 184/102 can be considered as hypertensive crises patient.

19. In patient of urinary tract infection, there is increased levels of white blood cells in the urine of the patient.

20. Normal characteristics of urine are as follows:

Color : Pale yellow to deep amber

Odor : Odorless

Volume : 750 – 2000 mL/24 hour

pH : 4.5 – 8.0

Specific gravity : 1.003 – 1.032

Osmolarity : 40 – 150 mOsmol/kg

Urobilinogen : 0.2 – 10 mg/100 Ml

White blood cells : 0 – 2 HPF (per high-power field of microscope)

Bilirubin : ?0.3 mg/ 100 Ml

21. Shortness of breath is also called as dyspnea, is an uncomfortable condition in which their discomfort in the taking oxygen inside the body. Due to sheerness of breath, there can be increase in the respiratory rate. This condition can occur mainly due to malfunctioning of lungs and heart. Some people can experience shortness of breath for short time and other people can experience for longer duration like weeks and more.

22. Client with fasting glucose level 3.1mmol/l in fasting condition can be considered as Hypoglycaemic condition.

23. Formula for calculating BMI is body weight (kg) / height (m).

24. A person with BMI 33.4 can be considered as class I obesity.

25. Normal blood sugar levels :

Fasting - 3.9–5.5 mmol/L

Two hours after meals - 7.8 mmol/L

26.

Stages	Conflict to be resolved	Examples
Oral-Sensory (birth to 1 year)	Trust vs mistrust	Parents of baby provide him with food and shelter and make him or her comfortable.
Musculo-Anal (1-3 Years)	Autonomy vs Shame and Doubt	Child can feel shameless when he observes other children of his or her age feed themselves.
Locomotor-Genital (3-5 Years)	Initiative vs Guilt	If child can not accomplish task on their own, they might feel guilty.
Latency (6 -11 Years)	Industry vs Inferiority	If child can not accomplish task on their own, they might feel inferior.
Adolescence (12-18 Years)	Identity vs Role Confusion	Adolescence become confused when that can not decide whether particular activity is appropriate to their age.
Young Adulthood (19-35 Years)	Intimacy vs Isolation	In this stage, young adults feel lonely because they interact with many people; however most of them could not find very close to them.
Middle adulthood (40 to 65 years)	Generativity versus Stagnation	These people should contribute significantly to society improvement. Failing to achieve this might keep tag as unproductive to them.
Maturity (65 to death)	Ego Integrity vs Despair	It is possible that these people can feel that they didn’t achieved much in life.

27. Airway, breathing and circulation (ABC) and Glasgow coma scale (GCS) need to used for the assessment of patient with fall and subsequent fall.

Standard spirometry and lung volume measurements can be used for assessment of dyspnea.

Blood glucose levels assessment using glucose strips and HbA1c levels can be used for the assessment of diabetes client.

Patient with pain on micturition can be assessed assessing urinary tract infection through analysing presence of microorganisms in the urine.

Pain assessment can be done in a patient with plaster after fracture.

28.

The Total intake for the day is	1260
The total output for day is	650
Is Mr Midler in a positive or negative fluid balance?	Mr. Mildler in positive fluid balance.

29. Urine analysis can be useful in identifying urinary tract infection, kidney stones, estimating urine sugar levels, blood, ketone bodies and bilirubin.

30. Bradycardia is a condition with very low heart rate usually below 60 beats per minutes at resting condition.

Tachypnea is a condition with rapid breathing rate usually greater than 20 breaths per minutes.

Cyanosis is defined as the bluish or purplish discolouration of the skin or mucous membranes due to the tissues near the skin surface having low oxygen saturation.

Hypotension can be defined as the below normal blood pressure than expected blood pressure for a particular individual in the provided condition and environment.

31. Jaundice can be defined as a medical condition which caused by excess amount of bilirubin pigment and also caused by obstruction of the bile duct, by liver disease and by excess breakdown of red blood cells which results in the skin yellowing and eyes whitening.

Pallor can be defined as pale color of the skin due to reduced oxyhaemoglobin levels which mainly occurs due to illness, emotional shock or stress, stimulant use and anaemia.

Turgor can be defined as elasticity of skin which can be useful in the assessment of degree of dehydration or fluid loss.

Petechial can be defined as red, brown or purple colored pinpoint, round spots which appear on the skin due to bleeding.

32. When completing a nursing assessment, data that is the client’s perception, ideas and sensations is known as subjective data.

33. Holistic assessment is the integral part of the nursing practice. Holistic assessment includes philosophy of holism balancing art and science which is helpful in establishing relationship among body, spirit and mind. Holistic assessment include assessment of all the aspects like emotional, psychological, biochemical, historical, spiritual and social. Holistic assessment can be helpful to inform nursing process and to establish foundation for patient care. Holistic assessment can be helpful in improving therapeutic communication, expanding subjective and objective data collection and improving person centred care to the patient.

34. Characteristics of Glasgow Coma Scale include eye response, verbal response and motor response.

35. Part A :

Complete medical history and physical examination need to be taken. Lethargy, fever, volume depletion, weight loss, bilious vomiting, haematemesis, papilloedema, abdominal tenderness, or the presence of a mass are red-flag symptoms need to be assessed. Vomiting and diarrhea need to be assessed for bacterial, viral gastroenteritis and Giardiasis. Accurate assessment is required in children because earliest intervention is required in the children. Children can not express their sufferings. Hence, nurse need to depend completely on accurate assessment for providing accurate intervention.

Part B :

Stat dose prescribed by Medical Officer need to be stopped. Information related to the child’s medicine allergy need to be collected and child need to assess for the allergy to the medicines. Dose of the medicine need to reduce allergic reaction and in case dose reduction is not effective in reducing allergic reaction, alternate medicine need to be administered.

36. Requirements of the discharge plan include :

Reason for patient’s admission to the hospital.

Vital signs along with pain severity and its management strategies.

Readmission risk.

Capability to pay for medicines.

Patient’s access to non-healthcare services and community-based services.

Referrals for community-based services.

Schedule for follow-up services.

Medication list.

37.

Part A

Select appropriate size blood pressure cuff.

Wrap the blood pressure cuff around upper arm.

Smoothly press the stethoscope's bell over the brachial artery just below the cuff's edge.

Quickly inflate the cuff to 185mmHg and release air from the cuff.

Listen stethoscope and observe sphygmomanometer to record blood pressure.

Part B

Use of inappropriate size cuff can result in increase in blood pressure reading.

Arm position and inflation/deflation method can result in increase in blood pressure reading.

38. He should be explained that asthma is a long-term condition. He Should be explained about cause behind wheezing, breathlessness and warning signs of asthma exacerbations. He should be educated about risk factors of asthma like colds, exercise, allergens, tobacco smoke which can trigger his asthma symptoms. He should be explained about procedures to use relievers and how these relivers can widen the constricted airways which can be helpful for easy breathing. He should be educated that relivers should be used optimally and these should be overused. He should be educated that preventers should be used on regular basis to achieve maximum effectiveness. He should be explained side effects of relivers and preventers. He should be educated and demonstrated use of inhaler devices like puffer and spacer. He should be demonstrated about cleaning and caring of inhalers and spacers.

39. Every child grows and develops differently. Hence, there can be milestones can be different in every child. Normal milestones can be achieved in a child by effective parenting. Parents and health workers need to give attention to health concerns, safety issues, nutrition, self-esteem, education, and socialization to achieve normal milestones for Zoe. Parents need to help Zoe to develop new skill and reach their fill potential. Zoe can acquire all the skills at the optimum speed; however, it is not mandatory that she can achieve all the milestones at the same time as her older siblings. She can achieve it either earlier or later stage in comparison to her siblings.

40.