HLTEN503B Student Booklet

Learning Resource Booklet | 24/03/2015 careersaustralia.edu.au 1

CONTRIBUTE TO CLIENT ASSESSMENT AND DEVELOPING NURSING CARE PLANS

HLTEN503B

Learning Resource Booklet | 24/03/2015 careersaustralia.edu.au

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CONTENTS

LEARNING RESOURCE BOOKLET ..................................................................................... 4

HUMAN GROWTH, DEVELOPMENT & FUNCTIONAL NEEDS ............................................... 6

Activity 1: Growth and development .............................................................................. 6

Activity 2: Growth and development scenarios ................................................................ 15

NURSING PROCESS & CLIENT ASSESSMENT (SYSTEM APPROACH) ............................... 22

Activity 1: Collection information .................................................................................. 22

Activity 2: Identification of correct diagnoses ................................................................. 24

Activity 3: Nursing care plans ....................................................................................... 28

Activity 4: Data collection admission note Part 1 .......................................................... 32

TAKING CLIENT, HISTORIES, PHYSICAL ASSESSMENT VITAL SIGNS ......................... 34

Activity 1: Data collection vital signs admission note Part 2 ........................................... 34

Activity 2: Vital signs quiz ........................................................................................... 36

Activity 3: Data collection - skin integrity assessment ...................................................... 40

URINALYSIS, SPECIMEN COLLECTION & PAIN ASSESSMENT ........................................ 44

Activity 1: Urinalysis and specimen collection ................................................................. 44

Activity 2: Pain assessment ......................................................................................... 46

NEUROLOGICAL & NEUROVASCULAR OBSERVATIONS & BGL ........................................ 52

Activity 1: Specific observation ..................................................................................... 52

Activity 2: Neurological observations (Lab practice) ......................................................... 56

ADMISSION & DISCHARGE PLANNING ......................................................................... 60

Activity 1: Admissions with different age groups ............................................................. 60

Activity 2: Nursing care plans and development stages .................................................... 62

CLIENT ASSESSMENT SKILLS ........................................................................................ 69

Activity 1: LAB case scenarios ...................................................................................... 69


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LEARNING RESOURCE BOOKLET

STUDENT BOOKLET

Course Code Course Title

HLTEN503B Contribute to client assessment and developing nursing care plans

Check list

Section Activity Title Activity Number

Session 1 Human growth, development & functional needs

Growth and development 1

Growth and development scenarios 2

Session 2 Nursing process & client assessment (system approach)

Collect information 1

Identification of correct diagnoses 2

Nursing care plans 3

Data collection admission note Part 1 4

Session 3 Taking client, histories, physical assessment vital signs

Data collection vital signs admission note Part 2 1

Vital signs quiz 2

Data collection (skin integrity assessment) 3

Session 4 Urinalysis, specimen collection & pain management

Urinalysis and specimen collection 1

Pain assessment 2

Session 5 & 6 Neurological & Neurovascular observation

Specific observation 1

Neurological observations (lab session) 2


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Session 7 Admission & Discharge planning

Admissions with different age groups 1

Nursing care plans and development stages 2

Session 8 Client assessment skills

LAB case scenarios 1


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HUMAN GROWTH, DEVELOPMENT & FUNCTIONAL NEEDS

Activity 1: Growth and development

STUDENT INSTRUCTIONS

The following activity requires students to:

1. Select one (1) of the following developmental age groups:

Infant to late childhood Adolescence Younger adulthood Older adulthood

2. Work in pairs to research your chosen developmental age group

3. Answer the questions provided for your chosen developmental age group below

HINT TIP

The following activity will provide you with the necessary knowledge required to answer Activity 2: Growth and development scenarios and prepare you for your exam.

READINGS

Students are required to refer to the following textbooks:

Hendry C et al (2012) Development, growth and repair from conception to old age. Nursing Standard, vol. 26, no. 50, pp. 44-49.

Tabbners 6th Edn, 2013 Theories of growth and development: Chapter 10, 11, 12 & 13.

INTERACTIVE ZONE

Lets get interactive!

Find articles on EBSCO host or read textbooks to answer the questions below.

EBSCO host Online Research Database

www.ebscohost.com


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What are the cognitive development/changes in infant to late childhood?

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What are the physical development/changes in infant to late childhood?

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What are the psychosocial development/changes in infant to late childhood?

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Infancy is the stage of development from birth to 12 months. There are multiple areas of growth and development that occur throughout infancy and early childhood (Tabbners 2013).

INFANT TO LATE childhood

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What are the common health risks/problems in infant to late childhood?

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What are the common health promotion/needs in infant to late childhood?

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What factors influence growth and development in infant to late childhood?

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List any specific developments or changes seen during infant to late childhood.

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What are the cognitive development/changes in adolescence?

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What are the physical development/changes in adolescence?

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What are the psychosocial development/changes in adolescence?

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ADOLEscence

Adolescence is the period of development from age 12 to 20 and is the stage that marks the transition from childhood to adulthood (Tabbners 2013).

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What are the common health risks/problems in adolescence?

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List any specific developments or changes seen during adolescence.

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What factors influence growth and development in adolescence?

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What are the common health promotion/needs in adolescence?

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What are the cognitive development/changes in younger adults groups?

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What are the physical development/changes in younger adults groups?

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What are the psychosocial development/changes in younger adults groups?

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Younger adulthood is a period of development from 19-20 years, is the period when a person transitions to maturity, independence and considerable social change (Tabbners 2013).

YOUNGER adulthood

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What are the common health risks/problems in younger adults?

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List any specific developments or changes seen in younger adults.

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What factors influence growth and development in younger adults?

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What are the common health promotion/needs in younger adults?

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What are the cognitive development/changes in older adulthood?

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What are the physical development/changes in older adulthood?

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What are the psychosocial development/changes in older adulthood?

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Old age consists of ages nearing or surpassing the life expectancy of human beings, and thus the end of the human life cycle (Tabbners 2013).

OLDER adulthood

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What are the common health risks/problems in younger adults?

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List any specific developments or changes seen in younger adults.

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What factors influence growth and development in younger adults?

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What are the common health promotion/needs in younger adults?

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Activity 2: Growth and development scenarios


Lets put theory into practice!

Students are required to read the case studies below and answer the questions provided.

HINT TIP

The following exercise will provide you with the necessary knowledge required to prepare you for your upcoming exam.

Scenario one (1): Infant

Nina is a twenty-two (22) year old and has attended the maternal-child health clinic with her eight (8) week old baby for a routine check-up. Nina is curious about the stages of infant development and asks, How is my baby doing? How long should she be and how much should she weigh now? When will she start smiling and trying to roll onto her back? Is there anything that I need to be careful of when I look after my little girl?

1. What subjective and objective data do you need to collect before you answer Nina?

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2. What would you tell Nina in response to all of her questions?

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Scenario two (2): Children

Anna, a three (3) year old girl, is admitted to your ward following a fall sustained in the home. She weighs 35kg and you notice on admission that there is a bruise on her back, she is very pale and does not attempt to communicate, either verbally or physically with you. You ask her mother if she is normally very quiet and she tells you she never speaks, she just sits and watches television all day. I sometime get frustrated because she does not respond until I shout out to her.

3. What physical and psychological factors may be affecting Annas growth and development?

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4. What health risks or problems are evident with Annas case?

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5. Complete the table below

List three (3) actual problems with Anna

List the nursing intervention(s) that can be utilised to improving/solving the problems?

What are the expected outcomes?

Problem 1

Problem 2

Problem 3

Scenario three (3): Adolescence

You are employed in a clinic. As you were walking out of the treatment room, you noticed that a rather untidy looking girl, of about fifteen (15) years of age, has walked into the reception area. You approached her to find out what she required and she tearfully started to explain to you that she thinks that she may be pregnant. She does not know when her last period was and is not really clear when she had sexual intercourse.

6. What subjective and objective data do you need to collect?

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7. What support and education will you be able to provide to the girl?

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8. List three (3) actual problems, two (2) potential problems, nursing interventions linked to each problem and what are expected outcome after each intervention.

List three (3) actual problems List the nursing intervention linked to each problem

What are the expected outcome(s)?

List two (2) potential problems List the nursing intervention linked to each problem



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Scenario four (4): Younger adults

Steven is a thirty-eight (38) year old bus driver and has been admitted to the ward with chest pain. He states he has been experiencing pains for a week and on the advice of his wife, he decided he would see his GP. Steven is overweight and admits not exercising as much as he did when he was younger. He has not had any health screening lately and feels he has not experienced any general health issues associated with being overweight. Steven smokes half a packet of cigarettes a day, but does not drink alcohol. On admission he states, I was under a lot of pressure with my company making a few redundancies in the last three (3) months. Thankfully, my wife and three (3) kids has been very supportive.

9. What subjective and objective data do you need to collect?

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10. What support and education will you be able to provide to Steven?

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11. List three (3) actual problems, two (2) potential problems, nursing interventions linked to each problem and what are expected outcome after each intervention.

List three (3) actual problems List the nursing intervention linked to each problem


List two (2) potential problems List the nursing intervention linked to each problem



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Scenario five (5): Older adulthood

Joseph is 72 male who was admitted to hospital, following a fall at home. He has a haematoma on his arm and on his face but has not sustained any major injuries. It is day three (3) of his hospitalisation, and you noticed that he is not his usual self today. When you inform him he has a visitor waiting to see him, he says he does not want to move and wants to stay in his bed today.

12. What issues do you think may have led to Joseph falling at home?

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13. What could be the reason for Josephs response about having no visitors?

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14. What aspect of care will you consider in planning his discharge?

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NURSING PROCESS & CLIENT ASSESSMENT (SYSTEM APPROACH)

Activity 1: Collection information


Students are required to read the Clinical scenario Box 15.1: the assessment phase and then divide the relevant information collected from the scenario into categories.

The categories are as follows:

Medical history Nursing history Subjective data Objective data Medical diagnosis Nursing diagnosis (actual or potential)

READINGS


Clinical scenario Box 15.1: the assessment phase on page 263 of the Tabbners 6th Edn, (2013).

Medical history

Nursing history


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Subjective data

Objective data

Medical diagnosis

Nursing diagnosis

(actual or potential)


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Activity 2: Identification of correct diagnoses


Students are required to read the scenarios below and identify the medical and nursing diagnosis for each of the following clients.

READINGS


Clinical scenario Box 15.1: the assessment phase on page 263 of the Tabbners 6th Edn, (2013).

Client one (1)

Frank, 67yo, complains of stubborn, old muscles. He has difficulty walking, evidenced by his shuffling gait. During the nursing history, Frank speaks in a monotone and seems very depressed. When the EN assesses the general appearance of Frank, they notice a pill-rolling tremor. Lab tests reveal a decreased dopamine level.

(See YouTube link: https://www.youtube.com/watch?v=0-t4RTQ0EsM).

1. Identify the medical and nursing diagnosis for Frank.

Medical diagnosis

Nursing diagnosis



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Client two (2)

For five (5) days, Judy, 26yo, has had sporadic abdominal cramps of increasing intensity. Most recently, the pain has been accompanied by vomiting and a slight fever. She is bracing her R) iliac fossa and has her knees drawn up.

2. Identify the medical and nursing diagnosis for Judy.

Medical diagnosis

Nursing diagnosis


Client three (3)

During an extensive bout with Respiratory Tract Infections (RTIs) Tom, seven (7), complains of throbbing ear pain. Toms mother notes his hearing difficulty and Tom is scared that he cant hear properly. His tympanic membrane is red and bulging. Tom is holding his ear and crying.

3. Identify the medical and nursing diagnosis for Tom.

Medical diagnosis


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Nursing diagnosis


Client four (4)

Raman is a 46 year old man, with two (2) grown-up children and four (4) grandchildren. He has an elderly mother to look after and he has recently been diagnosed with hypertension. He also has a long-term history of asthma. He is very concerned with his new diagnosis and frustratingly stated I will not be able to look after my mother if I am unwell like this!

4. Identify the medical and nursing diagnosis for Raman.

Medical diagnosis

Nursing diagnosis



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Client five (5)

Peter, a 70yo male, has a long term history of right sided heart failure. He came to visit his GP with increased shortness of breath when performing his ADLs. He lives alone with no support network, in a flat which is located on level two (2) of his building that has no elevator. He appears untidy and states I get really out of breath while I am in the shower, so I tend to avoid having one.

Medical diagnosis

Nursing diagnosis



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Activity 3: Nursing care plans

PART 1


Students are required to read the scenario below and develop a nursing care plan for Kevin.

The nursing care plan requires you to consider the following:

Nursing diagnosis (patients needs) List two (2)- three (3) actual and potential problems with Kevin as a nursing diagnosis

Planning (nursing intervention required) Expected outcomes

READINGS


Gulanick & Myers (2010) textbook (Nursing care plans).

Kevin

Kevin is a 19 year old male, admitted with bilateral fractured wrists, after falling from a motor bike. He has significant pain and is anxious about being in hospital. He states that his pain score is 8/10 and is grimacing. You observe on admission that he speaks gruffly to his family and does not engage in conversation when you introduce yourself to him. He sates he is frustrated about needing help and wants to get out of here.


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Nursing Care Plan Kevin

Nursing diagnosis (patients need)

Planning

(Nursing intervention Required)

Expected Outcomes


PART 2


Students are required to read the scenario below and develop a nursing care plan for Mr. Giovanni.

The nursing care plan requires you to consider the following:

Nursing diagnosis (patients needs) Planning (nursing intervention required) Expected outcomes

READINGS


Gulanick & Myers (2010) textbook (Nursing care plans).

Mr. Giovanni - 55yo

Having an elective surgery of Total Knee Replacement tomorrow Has history of Type II Diabetes Mellitus Non-English speaking background Independent with his ADLs Lives alone in a unit Has a son and daughter who are grown up in Australia, but very difficult to get in touch

with

You need to complete the admission assessment and documentation Also, the doctor wants you to carry out discharge education for Mr Giovanni Fasting from midnight (Mr. Giovanni has not been informed yet)


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Nursing Care Plan Mr. Giovanni

Nursing diagnosis (patients need)

Planning

(Nursing intervention Required)

Expected Outcomes

Actual/potential problem (circle the correct response)





Activity 4: Data collection admission note Part 1


Students are required to read the scenario below and complete the admission note using the information provided in the scenario.

HINT TIP

Students please note, this activity is part one (1) of a two (2) part activity. You must complete this after before you attempt activity one (1) Data collection (vital signs admission notes, in session two (2).

Scenario One (1)

You are admitting an Aboriginal male client to your ward for surgery this afternoon. Eddie Fisher is a forty (40) year old man and lives with his partner and their five (5) children. He sustained a knee injury playing rugby and has torn his cruciate ligament in his left knee. He walks with crutches as he is unable to weight bear.

He is well supported by his family and his partner and children. He smokes 10-15 cigarettes a day and is a non-drinker. He is anxious about his admission because he has a needle phobia.


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ADMISSION NOTES

DATE NAME

AGE ON ADMISSION

GENDER

RELIGION

CULTURE

SOCIAL SUPPORT

COPING MECHANISMS

SOCIAL

HEALTH NEEDS

ADL ASSESSMENT:

DIET OUTPUT MOBILISATION HYGIENE

DIET:

OUTPUT:

MOBILISATION:

HYGIENE:

CLIENT CONCERNS AND NEEDS RE: ADMISSION


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TAKING CLIENT, HISTORIES, PHYSICAL ASSESSMENT VITAL SIGNS

Activity 1: Data collection vital signs admission note Part 2


Students are required to read the scenario below and determine whether the information provided is subjective data, objective data or additional information.

Record your responses on the observation chart provided.

Scenario

You are admitting an Aboriginal male client to your ward for surgery this afternoon. Eddie Fisher is forty (40) year old man and lives with his partner and their five (5) children. He sustained a knee injury playing rugby and has torn his cruciate ligament in his left knee. He walks with crutches as he is unable to weight bear.

He is well supported by his family and his partner and children. He smokes 10-15 cigarettes a day and is a non-drinker. He is anxious about his admission because he has a needle phobia.

Observation on admission were:

T: 37.0 P: 94 R: 24 BP: 110/70 HEIGHT: 178 WEIGHT: 80kg BMI: 25 URINALYSIS: nil abnormal


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Observation Chart


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Activity 2: Vital signs quiz


Students are required to answer the following questions.

1. During the assessment stage, it is often appropriate to offer health teaching about findings, when taking vital signs. Which of the following statements, by the nurse, is the most appropriate after taking a clients vital signs?

a) Your hypertension is under control.

b) You have pitting oedema and mild varicosities.

c) Your pulse is 80 beat per min. This is within normal range.

d) I am using my stethoscope to listen for crackles and wheezes.

2. A patient has just finished eating ice. What would be the most appropriate site to take his temperature?

a) Rectal

b) Axillary

c) Oral

d) Tympanic

3. A patient had a bilateral fracture of the wrists. The most appropriate pulse point to use would be_____________

a) The femoral artery.

b) The carotid artery.

c) The dorsalis pedis.

d) The fontanelle.

4. Normal respiratory rate for a young adult should be _____________

a) 28-40 bpm.

b) 20-28 bpm.

c) 16-20 bpm.

d) 10-14 bpm.

5. Your patient is experiencing pain from an injury, which has increased their respiratory rate. An increased breathing rate is known as____________

a) Dyspnoea.

b) Orthopnoea.

c) Tachypnoea.

d) Hypoventilation.


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6. Difficulty breathing in medical terminology is known as ______________

a) Dyspnoea.

b) Orthopnoea.

c) Tachypnoea.

d) Hypoventilation.

7. Low blood pressure in medical terminology is known as __________

a) Pulse pressure.

b) Hypertension.

c) Hypotension.

d) Systolic pressure.

8. Normal blood pressure for a young adult should be__________

a) 120 / 80.

b) 180 / 95.

c) 140 / 80.

d) 80 / 45.

9. Diastolic pressure is defined as __________

a) The wave of expansion in an artery.

b) The relaxation stage of the cardiac cycle.

c) Above the acceptable normal level.

d) The contraction phase of the cardiac cycle.

10. The term febrile is defined as ______________

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11. List four (4) variables that can affect the temperature range of adults?

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12. What is the correct practice for the collection of a urine specimen, after a ward urinalysis showed (++) leukocytes?

a) By inserting a urinary catheter.

b) MSU.

c) By inserting a needle into the bladder.

d) Use the already collected urine used for urinalysis.

13. Why is routine mid-stream urine collected at the time of a client admission?

a) Establish a diagnosis.

b) Establish baseline observations.

c) Establish the volume of urine.

d) Establish the patients voiding pattern.

14. What Information is normally recorded after performing a routine urinalysis?

a) SG, pH, clarity & colour.

b) Blood, volume, clarity & pH.

c) Leucocytes, blood, volume & clarity.

d) Specific gravity, pH, volume, clarity, odour & colour.

15. What one (1) abnormality would you expect to be present in the urine, if a patient had a urinary tract infection?

a) Leukocytes.

b) Glucose.

c) Urobilinogen.

d) Ketone bodies.

16. What is the appropriate procedure for sending the sample to the laboratory, after MSU collection?

a) Leave labelled specimen in the pan room, until someone has time to collect it.

b) Double bag the specimen and send to the lab immediately.

c) Place the labelled specimen jar into a transport bag and take to the appropriate collection site.

d) Double bag the specimen and place in the refrigerator.

17. Neurovascular observations are completed on Sebastian. What are the components of Neurovascular observations that the EN can assess?

a) Colour, temperature, pain, sweating and pulse.

b) Colour, temperature, movement, sensation and pulse.

c) Pulse, sweating, sensation, pain and pressure.

d) Colour, movement, pulse, pressure and dexterity.


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18. Identify two (2) common tools, used to assess pain?

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19. List two (2) common objective data, you may collect when a patient is in pain?

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20. What does a Blood Glucose Level (BGL) of 13mmol/l indicate?

a) Hyperglycaemic.

b) Higher than normal but satisfactory for some patients.

c) Hypoglycaemic.

d) Within the normal range for diabetes mellitus.

21. Presence of Ketones in urine indicates, that inadequate insulin may _________

a) Cause protein in muscle to be used to produce energy.

b) Lead to breakdown of fats to provide an alternative source of energy.

c) Result in excessive breakdown of carbohydrates for energy.

d) Allow an increase in the production of amino acids for energy.

22. What is considered to be a normal range for Blood Glucose Levels (BGLs)?

a) 2-4 mmols

b) 4-8 mmols

c) 8-13 mmols

d) 13-19 mmols

23. List the normal ranges for adult vital signs?

Normal ranges for adult vital signs

T RR

HR BP

SpO2


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24. What are two (2) health risks associated with a low BMI?

_____________________________________________________________________

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25. What are two (2) health risks associated with a high BMI?

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Activity 3: Data collection - skin integrity assessment

PART 1


Students are required to read the scenario below and determine whether the information provided is subjective data, objective data or additional information.

Record your responses in the table provided.

Scenario

You are looking after an elderly client, Mavis Berkely, 84yo female with urinary incontinence. She is 170cm, weight 60kg, BMI 18. She has bony prominences to her hips, coccyx and shoulders. She is bed-ridden following a stroke and has limited sensation to her left side. She eats small meals and needs encouragement. When she sits out in a chair she tends to slump and slide and therefore needs frequent re-positioning.

Subjective data Objective data Additional information gathered


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PART 2


Students are required to read the scenario below and complete a Braden Scale skin integrity assessment.

Scenario

You are looking after an elderly client, Mavis Berkely, 84yo female with urinary incontinence. She is 170cm, weight 60kg, BMI 18. She has bony prominences to her hips, coccyx and shoulders. She is bed-ridden following a stroke and has limited sensation to her left side. She eats small meals and needs encouragement. When she sits out in a chair she tends to slump and slide and therefore needs frequent re-positioning.


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BRADEN SCALE SKIN INTEGRITY ASSESSMENT (circle the correct answers)

SEVERE RISK: Total score 9 HIGH RISK: Total score 10-12

MODERATE RISK: Total score 13-14 MILD RISK: Total score 15-18

DATE OF ASSESSMENT:

SENSORY PERCEPTION

Ability to respond meaningfully to pressure-related discomfort

1. COMPLETELY LIMITED Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation, OR limited ability to feel pain over most of body surface.

2. VERY LIMITED Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR has a sensory impairment which limits the ability to feel pain or discomfort over of body.

3. SLIGHTLY LIMITED Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.

4. NO IMPAIRMENT Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

MOISTURE

Degree to which skin is exposed to moisture

1. CONSTANTLY MOIST Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

2. OFTEN MOIST Skin is often but not always moist. Linen must be changed at least once a shift.

3. OCCASIONALLY MOIST Skin is occasionally moist, requiring an extra linen change approximately once a day.

4. RARELY MOIST Skin is usually dry; linen only requires changing at routine intervals.

ACTIVITY

Degree of physical activity

1. BEDFAST Confined to bed.

2. CHAIRFAST Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.

3. WALKS OCCASIONALLY Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.

4. WALKS FREQUENTLY Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.

MOBILITY

Ability to change and control body position

1. COMPLETELY IMMOBILE Does not make even slight changes in body or extremity position without assistance.

2. VERY LIMITED Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3. SLIGHTLY LIMITED Makes frequent though slight changes in body or extremity position independently.

4. NO LIMITATIONS Makes major and frequent changes in position without assistance.


NUTRITION

Usual food intake pattern

1. VERY POOR Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement,

2. PROBABLY INADEQUATE Rarely eats a complete meal and generally eats only about of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement

3. ADEQUATE Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally refuses a meal, but will usually take a supplement if offered,

4. EXCELLENT Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

FRICTION AND SHEAR

1. PROBLEM- Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.

2. POTENTIAL PROBLEM Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3. NO APPARENT PROBLEM Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

Total Score

Source: Barbara Braden and Nancy Bergstrom. Copyright, 1988. Reprinted with permission.


URINALYSIS, SPECIMEN COLLECTION & PAIN ASSESSMENT

Activity 1: Urinalysis and specimen collection


Students are required to complete the following questions.

1. What are the normal ranges of urinalysis?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

2. What are the differences in between performing urinalysis and collecting MSU?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

3. What three (3) features are checked with a visual examination of a urine specimen?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________


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4. Fill in the blanks.

Incontinent Soiling Perineal area Elimination

Perineal care is cleansing of the _____________________________ a hygiene and comfort

measure. It is done during the daily bath as well as anytime it is necessary due to

________________ during _______________ or _______________ episodes.

5. Gathering equipment is a time-management strategy. What types of equipment would have to gather when conducting urinalysis?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

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Activity 2: Pain assessment

PART 1


Instructions for nurses

Pretend that you are working in the hospital so that it is necessary to talk to the patient in an appropriate manner. You will need to ask PQRST, to perform a thorough pain assessment.

Students are required to:

1. Take turns at being a patient and the nurse. Use all three (3) pain assessment tools with different types of pain.

2. Talk to your patient in the appropriate manner and language.

3. Patient role must pretend that you are in pain.

4. Practice using common pain assessment tools as below as well as PQRST

** remember these tools are to assess the intensity/ severity of the pain only

PQRST (Examples of questions for PQRST for nurses use)

P: What were you doing when the pain started?

Possible response

I was just lying in my bed resting

Q: Can you describe your pain? Is it sharp? Dull? Stabbing like?

Possible response

It is aching

R: Does the pain spread anywhere? Can you show me where it goes?

Possible response

It is goes around my ribs, here to there

S: How bad is your pain? Can you scale 0-10? 0 is no pain 10 is the worst pain you have ever experienced.

Possible response

It is six (6) out of ten (10)


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T: How long did the pain last? Is it still there or comes and goes?

Possible response

It is always there

Other possible responses

I do not speak English!

I not understand!!!

I have pain!

Very bad!!

.............. no response

sad face

sobbing or occasional moan

Rigid

Use your imagination


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Visual Analogue Scale (VAS)

Cover the numbered scale. Do not show the patient the numbered scale.

Instruct the patient to point to the position on the line between the faces, to indicate how much pain they are currently feeling. The far left end indicates No pain and the far right end indicates Worst pain ever.

Numerical rating scale (NRS)

Instruct the patient to choose a number from 0 to 10, which best describes their current pain.

0 would mean No pain and 10 would mean Worst possible pain.


Faces rating scale (FRS)

Cover the numbered scale. Do not show the patient the numbered scale.

Adults, who have difficulty using the numbers on the visual/numerical rating scales, can be assisted with the use of the six facial expressions, suggesting various pain intensities. Ask the patient to choose the face that best describes how they feel. The far left face indicates No hurt and the far right face indicates Hurts worst. Document the number below the face chosen.

PART 2


Students are required to role play the following activity.

This is an activity-related score. Observe your patient while performing an activity related to their painful area (for example, deep breathe and cough for thoracic injury or move affected leg for lower limb pain). Normally performed as a part of vital signs.


1. Take turns at being a patient and a nurse

Functional activity score

A No limitation meaning the patients activity is unrestricted by pain

B Mild limitation means the patients activity is mild to moderately restricted by pain

C - Severe limitation means the patient ability to perform the activity is severely limited by pain

** Relative to baseline refers to any restriction above any preexisting condition the patient may already have.


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Abbey Pain scale


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PART 3


Students are required to role play the following activity. You will need to pretend that your patient is unable to provide a self-report of pain: scored 010 clinical observation. Using this information, complete the Behavioural Rating Scale below.


1. Take turns at being a patient and a nurse

Behavioural Rating Scale

Face 0

Face muscles relaxed

1

Facial muscle tension, frown, grimace

2

Frequent to constant frown, clenched jaw

Face score:

Restlessness 0

Quiet, relaxed appearance, normal movement

1

Occasional restless movement, shifting position

2

Frequent restless movement may include extremities or head

Restlessness score:

Muscle tone* 0

Normal muscle tone

1

Increased tone, flexion of fingers and toes

2

Rigid tone

Muscle tone score:

Vocalisation** 0

No abnormal sounds

1

Occasional moans, cries, whimpers and grunts

2

Frequent or continuous moans, cries, whimpers or grunts

Vocalisation score:

CONSOL ability 0

Content, relaxed

1

Reassured by touch, distractible

2

Difficult to comfort by touch or talk

CONSOL ability score:

Behavioural pain assessment scale total (010) /10 * Assess muscle tone in patients with spinal cord lesion or injury at a level above the lesion injury. Assess patients with hemiplegia on the unaffected side. ** This item cannot be measured in patients with artificial airways.

Functional activity score#

(Cough/movement) A No limitation B Mild limitation C Severe limitation

#Relative to baseline


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NEUROLOGICAL & NEUROVASCULAR OBSERVATIONS & BGL

Activity 1: Specific observation

PART 1


Students are required to answer the following questions.

1. Is it normal to see Leukocytes in urine? What is the indication if presence?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

2. What is the normal pH of urine?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

3. What does pH measure?

_________________________________________________________________________

_________________________________________________________________________

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_________________________________________________________________________

4. What is normal specific gravity reading?

_________________________________________________________________________

_________________________________________________________________________

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5. When would be the occasion the urine has low or high reading of specific gravity?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

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6. What could the presence of bilirubin in urine indicate?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

7. What is the normal range for blood glucose level?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

8. What are ketones?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

9. What do ketones in the urine indicate?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

10. Define MSU.

_________________________________________________________________________

_________________________________________________________________________


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11. What would you do with a urine specimen once you have obtained it?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

12. Demonstrate on your partner how you would assess Glasgow Coma Scale (GCS) when performing neurological observations on a client.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

13. What does a score of three (3) indicate on the GCS?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

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14. Assume the person sitting beside you has been to a surgical procedure for closure of a compound fracture of their R) wrist perform a set of neurovascular observations on their R) wrist.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

15. Perform pain assessment on your partner. (Use PQRST and numeric pain scale)

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

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16. Why do we record a clients height and weight?

_________________________________________________________________________

_________________________________________________________________________

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_________________________________________________________________________

17. Define BMI.

_________________________________________________________________________

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18. Write the formula for calculating BMI.

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19. Identify the BMI range for underweight, normal, overweight and obese?

_________________________________________________________________________

_________________________________________________________________________

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20. Calculate BMI for someone who is 165cm tall and weighs 90 kg.

_________________________________________________________________________

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Activity 2: Neurological observations (Lab practice)


Lets get practical!

Use the chart below during the discussion, and record the result when you perform a neurological observation with your patients (other students in your group).

A list of possible neurological response has been provided below. The student who is role playing as a patient may use each cue card as a response during the assessment

Eye: Spontaneously

Verbal: Orientated

Motor: Obey Command

R) &L) arm & legs: full strength

Eye: To pain

Verbal: None

Motor: Extension

R) &L) arm & legs: extension to pain

Eye: To speech/name

Verbal: Orientated

Motor: Obey Command


Eye: To pain

Verbal: None

Motor: abnormal flexion

R) &L) arm & legs: flex to pain

Eye: To Pain

Verbal: Incoherent

Motor: Localise Pain

R) & L) arm: moderate weakness

R)& L) Leg : No response

Eye: None

Verbal: None

Motor: None

R) &L) arm & legs: No response

Eye: To speech/name

Verbal: Confused


R)& L) arm: full strength

R)&L) Leg: Mild weakness

Eye: To speech/name

Verbal: inappropriate


R) arm: flex to pain

L) arm extension to pain

R) leg: flex to pain

L) Leg extension to pain


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Eye: To pain

Verbal: Orientated

Motor: Obey Command


Eye: Spontaneously

Verbal: Confused

Motor: Obey commands

R) arm: severe weakness

L) arm extension to pain

R)+L) leg: severe weakness

Eye: To pain


Motor: Withdraws

R) arm: mild weakness

L) arm: full strength

R)+L) leg: full strength

Eye: Spontaneous



R)+L) arm flex to pain

R)+L) Leg flex to pain

Eye: To pain

Verbal: incoherent

Motor: abnormal flexion/flex to pain

R)+L) flex to pain

R)+L) flex to pain

Eye: None

Verbal: None

Motor: Extension

R) arm: extension to pain

L) arm: flex to pain

R) leg: extension to pain

L) Leg : flex to pain

Eye: To pain

Verbal: None

Motor: Withdraws

R)+L) Extension to pain

Eye: To speech/name


Motor: Obey Command

R)+L) arm: severe weakness

R)+L) Leg: moderate weakness

Eye: Spontaneously

Verbal: Orientated

Motor: Obey Command


Eye: To pain

Verbal: None

Motor: Extension

R)+L) arm & leg extension to pain


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ADMISSION & DISCHARGE PLANNING

Activity 1: Admissions with different age groups


Students are required to summarise the hospital admissions process for each of the following age groups:

Children Adolescents Adults Older adults

Each summary should include;

Psychological impact due to hospital admission Factors that may be affected, due to hospitalisation Nursing management to alleviate the impacts (DO NOT use the word

reassurance, provide specific management methods)

READINGS

Students are required to refer to the following textbook:

Tabbners 2013 (Chapter 19)page 334-337, 340-343

Children


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Adolescents

Adults

Older Adults


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Activity 2: Nursing care plans and development stages


Students are required to read the follow case studies and answer the questions provided below.

Older Adult

Mrs. Caroline is an eighty-five (85) year old women, who has a long term history of COPD, for

which she wears home oxygen 1L/min via nasal prongs and takes Seretide MDI (1 puff) daily.

She slipped and fell in her bathroom at home two weeks ago. She was diagnosed with

orthostatic hypotension. Mrs. Caroline has been transferred to the rehabilitation ward where you

are currently working.

On arrival to the ward, Mrs. Caroline is withdrawn and looks upset and worried. She relays to

you that is she is very nervous about getting her strength back within a certain period of time

and fearful about returning home by herself. She arrived to the ward by a patient transport

(ambulance) and was accompanied by her daughter who lives a twenty (20) minute away drive

from Mrs. Carolines house.

Observation on admission were:

T: 35.6 C P: 60 R: 18 BP: 92/56mmHg HEIGHT: 170 WEIGHT: 65kg BMI: 19 URINALYSIS: awaiting urination HR: 110 bpm RR: 24 bpm SpO2: 94% on 1L/min via nasal prongs

1. List four (4) specific health needs for Mrs. Carolines age group.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________


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2. List three (3) actual and three (3) potential problems with Mrs. Caroline, as a nursing diagnosis.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

3. Write admission note for Mrs. Caroline.

ADMISSION NOTES

DATE NAME

AGE ON ADMISSION

GENDER

RELIGION

CULTURE

SOCIAL SUPPORT

COPING MECHANISMS

SOCIAL

HEALTH NEEDS

ADL ASSESSMENT:

DIET OUTPUT MOBILISATION HYGIENE

DIET:

OUTPUT:

MOBILISATION:

HYGIENE:


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CLIENT CONCERNS AND NEEDS RE: ADMISSION

ADMISSION OBSERVATIONS:

T P R BP HEIGHT WEIGHT BMI URINALYSIS

T:

P:

R:

BP:

HEIGHT:

WEIGHT:

BMI:

URINALYSIS:

HR:

RR:

SpO2:

NURSING NOTES:

(sign off with name, signature and delegation at the end of the notes)


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Middle-aged Adulthood

Mr. Grey is fifty-five (55) year old male, who is newly diagnosed with Type 2 diabetes mellitus. His height is 175cm and weighs 101kg. He informs you that he has no idea what diabetes is. He does not know how he is going to look after himself at home. He has three (3) children who are 24, 21 and 16 year old. He is very concerned that the latest diagnosis can affect his working ability and financial situation. He knows that he needs to lose weight, but he is not very committed to regular exercise.

1. List four (4) major physiological changes that occur in his developmental stage.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

2. List two (2) specific health needs for Mr. Greys age group.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

3. List four (4) needs to be considered for Mr. Greys discharge, and write a discharge plan.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

4. Discuss how you would educate Mr. Grey about his concerns and medical condition.

_____________________________________________________________________

_____________________________________________________________________

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Young Adulthood

Barbara is twenty-nine (29) year old female, who presents with nausea, frequency and burning with urination. Barb also has lower back pain. She states my back is sore, in the middle, down on the right hand side. Her pain score is 3/10 and she is febrile. Her vital signs are: PR 92 beats per minute, BP 140/90mmHg, RR 20 breaths per minute. Temp 37.9 C. Barbara states that she has been to the toilet to urinate four times in the last half hour. You observe that Barbara is restless and unable to sit still, and keeps moving her legs when she does sit. Barbara appears anxious. She states it stings every time I go and when I finish I feel like I need to go again. She reports I feel sick waves of nausea, but she has not vomited.

1. List three (3) actual and three (3) potential problems with Barbara, as a nursing diagnosis.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

2. List major developmental stages that may be seen with Barbara.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Adolescence

Ben is a thirteen (13) year old male brought to an emergency department by his mother, after reporting vomiting and abdominal pain. You have collected the information that he had polyuria and excessive thirst, accompanied by a 3kg weight loss over the last two (2) weeks. His BGL was 21mmol/L on arrival and has come down to 15.8 mmol/L after administration of insulin. He was diagnosed with a Hyperglycaemic diabetic episode.

He has transferred to the paediatric ward for further management. On arrival to the ward, he is crying and upset. He is holding his arm and states that he has had enough with being so sick and fat! He also states, I didnt have to come to hospital, Im too scared, being away from home and I dont like the smell of hospitals, it makes me feel sick. His mother tells you that Ben was skipping his meals, as someone from school was teasing him about being chubby.

Ben was prescribed an insulin regimen, consisting of an insulin injection before breakfast and before bed. He also has to measure blood glucose levels four (4) times a day, from the day of discharge, onwards.


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1. Identify four (4) health risks/major issues, associate with this developmental age.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

3. List four (4) growth and developments that may be seen with Ben during middle adolescence.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

4. List three (3) actual and three (3) potential problems with Ben as a nursing diagnosis.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Childhood

Mackenzie is a five (5) year old girl, being admitted for an acute asthma attack. She is the youngest of three children all girls. Her parents are Debra and Hugh. Mackenzies older sister is ten (10) and has a disability that requires her mothers constant care. Her middle sister is seven (7). Debra is a stay at home mother and Hugh works full time as an Electrician and part-time packing shelves at the local grocery store. Hugh works very from7am-11pm five (5) days per week. Debra is the primary care giver of the children.

According to Debra, Mackenzie is a happy and well-adjusted child. She has just completed her Prep year at school. Her immunisations are up to date and she is achieving well in all her developmental milestones. Mackenzie has had asthma since she was very young and once a year, experiences an episode severe enough to require hospitalisation.

1. Discuss the impact of hospitalisation for Mackenzie and her family.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________


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2. Identify three (3) factors that influence the way a child and their family react when a child needs to be hospitalised.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

3. List two (2) actual and two (2) potential problems with Mackenzie, as a nursing diagnosis.

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________


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CLIENT ASSESSMENT SKILLS

Activity 1: LAB case scenarios


Lets get active!

The following activities will need to be completed in a clinical lab session. Educators will have practical stations organised. There are five (5) practical stations, they are as follows:

Station one (1) Holistic assessment Station two (2) Neurovascular observations Station three (3) Urinalysis Station four (4) Neurological observations Station five (5) Blood Glucose test

Each station will require you (the student) to:

1. Read the LAB case scenarios BEFORE partaking the practical component.

2. Complete three (3) to four (4) questions BEFORE you perform the clinical skills

3. Form groups of three (3) to four (4) people. One (1) person is required to play the role of patient.

4. Each student MUST take turns in playing the nurse and the patient.

5. Students are required to complete the required skills check. Once you have completed a skills task, tick the corresponding skill. An example has been provided below.

HINT TIP

The following exercise will provide you with the necessary knowledge and practical/clinical skills required for your upcoming OSCE exam.

READINGS

Students are required to refer to the following textbook:

Essential Clinical Skills


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Station one (1) Holistic assessment

Mr. Chen is forty-four (44) year old Chinese man, who migrated to Australia twenty-five (25) years ago. Mr. Chen has been referred to the hospital for various investigations of prostate cancer. Mr. Chen comes from a strict catholic background and he feels very insecure that he could not go to church last Sunday due to the illness. He has a long term history of Chronic Obstructive Pulmonary Disease, type 2 Diabetes Mellitus and peripheral vascular disease. Mr. Chenss uncle died from prostate cancer five (5) years ago. He tells you that he does not want any family members to find out about the investigations and any results at this stage. He has urgency of urination. He is getting angry at himself for neglecting his health.

Socioeconomic: Mr. Chen lives with his wife and two (2) teenage sons. He works in a trading company as a manager and travels in between China and Australia almost every month.

Before you perform the clinical skills, please complete the questions below in your group.

1. Normal ranges of temp, BP, HR, RR and Sp02 are?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

2. What is a holistic assessment? What information do you need to collect?

_____________________________________________________________________

_________________________________________________________

HLTEN503B Student Booklet

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Transcript of HLTEN503B Student Booklet