Nursing assessment and management of neurological health

Nursing assessment and management of neurological health

Nursing assessment and management of neurological health

Assessment Task Written Student Name Unit Code/s & Name/s Cluster Name If applicable Student Number HLTENN037 Perform clinical assessment and contribute to planning nursing care HLTENN038 Implement, monitor, and evaluate nursing care CLS-HLT-0071 Clinical Assessment and Care Planning Cluster Assessment Type ☒ Case Study Assessment Name Written general questions and case scenarios. ☒ Assignment Assessment Due Date ☐ Project ☐ Other (specify) Assessment Task No. Date Submitted 1 of 4 / / Assessor Name Student Declaration: I declare that this assessment is my own work. Any ideas and comments made by other people have been acknowledged as references. I understand that if this statement is found to be false, it will be regarded as misconduct and will be subject to disciplinary action as outlined in the TAFE Queensland Student Rules. I understand that by emailing or submitting this assessment electronically, I agree to this Declaration in lieu of a written signature. Student Signature Date / / PRIVACY DISCLAIMER: TAFE Queensland is collecting your personal information for assessment purposes. The information will only be accessed by authorised employees of TAFE Queensland. Some of this information may be given to the Australian Skills Quality Authority (ASQA) or its successor and/or TAFE Queensland for audit and/or reporting purposes. Your information will not be given to any other person or agency unless you have given us written permission or we are required by law. 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 1 of 14 Document1 Instructio ns to Student General Instructions: Read the general and workplace simulated case scenarios on the following pages and answer all 25 questions. Please review the marking criteria for this assessment to ensure you are providing the required information in your answers. All parts of each question are to be answered. APA referencing is to be used for all answers. When you are answering your questions, type the answer below each question. You may choose to put the question in bold format if you wish. Please do not change the font. Information / Materials provided: Open Book – to be completed on their own and submitted by the due date as stated in the unit guide Access to a computer and word processing software is required Assessment Criteria: To achieve a satisfactory result, your assessor will be looking for your ability to demonstrate the following key skills/tasks/knowledge as outlined in the marking criteria for this assessment task. Number of Attempts: You will receive up to two (2) attempts at this assessment task. Should your 1st attempt be unsatisfactory (U), your teacher will provide feedback and discuss the relevant sections / questions with you and will arrange a due date for the submission of your 2nd attempt. If your 2nd submission is unsatisfactory (U), or you fail to submit a 2nd attempt, you will receive an overall unsatisfactory result for this assessment task. Only one re-assessment attempt may be granted for each assessment task. For more information, refer to the Student Rules. Submissio n details Once completed, you upload the assessment to the AT1 drop box in Connect, ensuring that you follow the instructions carefully (there is an instruction video on the screen). If you are experiencing difficulties uploading your paper, contact your teacher before the due date. If you are unable to submit by this date, you must ask for an extension in writing at least 48 hrs before the due date. You can download an extension request form on CONNECT. Requests for extensions inside this seven-day deadline will not be approved unless you have a medical certificate. TAFE Queensland Learning Management System: Connect url: https://connect.tafeqld.edu.au/d2l/login File Name You should save this file in the following format (including the month and year your course started. This enables your teacher to download your assessments in alphabetical order: Your Surname_group_Number of assessment. Example: Wilson_Apr 2019_AT1 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 2 of 14 Document1 If you are required to resubmit an assessment, please name your files as follows: Your Surname_resubmit_group_number of assessment. Academic and research misconduct APA 7th edition style in-text referencing must be used throughout, and a reference list submitted with the assessment. Students must use their own words to answer the questions. Assessments that use, reproduce, or adapt the work or ideas of another person without due acknowledgment will be graded as unsatisfactory and considered academic misconduct. For more information, refer to the Student Rules Instructio ns for the Assessor Students are to attempt all assessment questions / tasks and submit for review and resulting by the due date. Please refer to QLD TAFE Student Rules and Policies for assessment and appeals processes: https://tafeqld.edu.au/about-us/policy-and-governance/policies-and-procedures/studentrules-and-policies/index.html Students are expected to complete unit content and personal study to assist in completing the assessment successfully. Assessors are to refer to the Benchmark Answers to ensure objectivity and consistency. Tafe assessor is to refer to Tafe Student Support Strategy if reasonable adjustment is required https://intranet.tafeqld.edu.au/sites/search/Pages/intranetresults.aspx?k=reasonable%20a djustment All aspects of the marking criteria must be met in order to achieve a satisfactory result for this assessment. Assessors must satisfy the Standards for Registered Training Organisations (RTOs) 2015/AQTF mandatory competency requirements for assessors. Note to Student An overview of all Assessment Tasks relevant to this unit is located in the Unit Study Guide. Q1.Identify two (2) characteristics for each of the five (5) components of the nursing process framework that you will use when conducting a health assessment. Components of The Nursing Process Framework Characteristics Assessment Identification ( also nursing diagnosis) 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 3 of 14 Document1 Planning Implementation ( actions) Evaluation Q2. Identify the factors that influence growth and development for the following: Modifiable factors non-modifiable Q3. For each of the identified areas of human growth and development in the table below, match it with the correct stage from the given list. LIST of stages. Infancy Middle childhood Preadolescence Young adult Middle adult Older adult Early childhood Adolescence Human growth and development Sexual maturity is achieved, with reproductive functions now evident. Relationships with parents are usually distanced, with peer relationships strengthened and prioritised. Risk taking behaviour Stage Adolescence Stage of development (1–6 years old) Early Childhood Stage of development from birth to 12 months Infancy Emotional development concerns adjustment to independent adult life and centres on the formation of adult relationships. 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 4 of 14 Document1 Turns head towards sounds. Rolls from prone to supine. Makes sounds when spoken to, may squeal with pleasure. Clasps hands together and can hold a rattle. Begins to watch own hands. Smiles and vocalises These changes alter susceptibility to various diseases and will frequently alter the efficiency of the functioning of the organ/organ systems The ability to think abstractly and to solve problems develops and improves. Verbal language skills are further developed with an increased vocabulary and fluency of speech, and the ability to read becomes a valuable means of increasing knowledge While this stage is commonly the healthiest time of life, health problems do occur and are generally related to lifestyle choices. Physical changes associated with puberty begin. Children become more social, and their behavioural patterns become less predictable This group is associated with many changes, people may experience doubt or anxiety about their sexual attractiveness or adequacy. The major developmental change influencing sexuality for women is the onset of menopause Stage of development (6-12 years old) Hypertension predisposes this group to heart failure and coronary disease, renal disease, peripheral vascular disease, stroke Older Adult Vocabulary of 1500+ words, uses sentences of 4–5 words, knows many letters of the alphabet and can count up to 10 Q4. Discuss genetic and environmental factors, and their influence on development. (max 100 words) 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 5 of 14 Document1 Case Scenario – relates to Q5 & 6 Bianca, 47 yrs old female ( identifies as she, her) was diagnosed with breast cancer a week ago, she has now undergone a double mastectomy and will be commencing chemotherapy in the near future. Bianca has been required to take an initial six weeks leave from work and Bianca’s partner Jenny has also taken time of work to support Bianca and their two children aged 12 and 15. Q5. Identify three (3) factors that may impact Bianca’s family due to her illness. Q6. Provide three (3) nursing actions to provide support for Bianca’s family and other family members / carers impacted by a person’s illness. Case Scenario Ann Buinda – relates to Questions 7-21 Ann Buinda is an Aboriginal female ( identifies as she, her) aged 55 yrs who lives in St George QLD and is admitted to a Brisbane hospital for a right knee replacement. Ann is accompanied by her niece Joanne who is 22yrs old. Ann suffers from osteoarthritis and uses 2 walking sticks to mobilize. She has treated her pain with overthe counter medications including paracetamol and ibuprofen. Ann is also a Type 1 insulin dependent diabetic and admits she is not always compliant with a diabetic diet. You ask Ann how she would like to be addressed and she says to call her Ann, Ann speaks her local Aboriginal language and English, Joanne also speaks English. Ann is very quiet and looked scared. Joanne has indicated to you that Ann is feeling quite anxious coming into hospital and being away from her community. As the Enrolled Nurse doing the admission documents you have taken a base line set of Observations and noted the following. • • • • BP 170/100 PR 90 regular RR 22 To 36.4 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 6 of 14 Document1 • • • • • SpO2 98% on room air BGL 10.4 mmol Weight 66 kg Height 152 cm GCS (Glasgow coma scale) = 15 Q7. Identify the purpose of the Congress of Aboriginal and Torres Strait Islander Nurses and Midwives (CATSINaM). Q8. According to the Nursing And Midwifery Board Code Of Conduct For Nurse’s, Identify four (4) aspects of culturally safe and respectful practice that you as the Enrolled Nurse can acknowledge to help Ann feel less anxious. Answer the following questions in relation to the assessment data in the Case Scenario for Ann. Q9. Ann’s blood pressure (BP) is 170/100. What artery is the blood pressure cuff placed over What is the generally accepted normal range for Systolic and Diastolic blood pressure in an Adult? 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Is Ann’s blood pressure reading within normal range? What is the correct terminology of high blood pressure? Page 7 of 14 Document1 Q10. Ann’s pulse rate is 90 and regular. What artery do you normally feel for when taking a person’s peripheral pulse When taking a person’s pulse what are you assessing What is the normal range for adult pulse rate? Is Ann’s pulse rate within normal range? Q11. Ann’s respiratory rate is 24. How do you count respiration rate on a person What is the normal range for respiratory rate in an adult? Is Ann’s respiratory rate within normal range? What is the correct terminology for low respirations? Q12. Ann’s temperature is 36.4. How would you take a person’s temperature using a Tympanic thermometer What is the normal range for adult temperature? Is Ann’s temperature within normal range? Identify two (2) other sites you can take a temperature reading from 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 8 of 14 Document1 Q13. Ann’s oxygen saturation (SpO2) is 98% on room air. If you are placing an oxygen sensor probe on a patient’s finger, what must you assess first to ensure that the site is appropriate What is the normal range for oxygen saturation? Is Ann’s SpO2 within normal range? Q14. Ann’s Blood Glucose Level (BGL) is 10.4 mmol. When using a Blood glucose meter device, what site on a person’s body is usually used to take a blood sample and why What is the normal range for blood glucose levels? Is Ann’s BGL within normal range? Q15. Ann’s Glascow Coma Scale (GCS) = 15. When performing a neurological assessment using the GCS, what six (6) areas do you assess and why 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Is Ann’s GCS normal and why? Page 9 of 14 Document1 Q16. Using the following formula calculate Ann’s BMI:- BMI = kg/m2 Ann’s BMI = Is this normal? Q17. Neurovascular Observation What areas on the body would you include for Ann when doing a Neurovascular assessment? What are you assessing (looking for) when palpating the pulses of the popliteal, posterior tibial and dorsalis pedis? What are you assessing (looking for) when palpating the extremities? Q18. As part of your admission assessment on Ann you are to check for bowel sounds – please answer the following questions. Gastrointestinal and Bowel sounds State two (2) inspections that are performed when assessing a patient’s abdomen. What are bowel sounds? State the equipment to be used to Auscultate a patient’s abdomen when checking for bowel sounds. 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 10 of 14 Document1 State the equipment to be used to Auscultate a patient’s abdomen when checking for bowel sounds. What sounds would you normally expect to hear? What maybe the problem if no bowel sounds are heard. Q19. As part of your admission assessment on Ann you are to complete a skin assessment – please answer the following questions. Skin assessment Identify four (4) factors that are important to consider when assessing the integumentary system (skin). How would you assess the skin turgor on Ann, and state what is normal / abnormal? Later in the shift Ann presses her call button, when you respond you notice that Ann is grimacing and is rubbing her knee. Her Niece explains that Ann is a lot of pain but doesn’t like to say anything. You are required to conduct a pain assessment. You will be using the PQRSTU tool to assess Ann’s pain. 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 11 of 14 Document1 Q20. Please state what each of the following letter stands for in the PQRSTU tool. PQRSTU P – Provocative Q – Quality R – Region S – Severity T – Timing U – U (you) Q21. Outline three (3) nursing actions you as a EN could provide for Ann’s pain, ( ensure these are relevant to her stay in hospital) 1. 2. 3. You are employed as an Enrolled Nurse in a community health service with a high proportion of Indigenous individuals and families. Your service is focused on providing culturally safe care that acknowledges the diversity of cultural needs among different Indigenous language groups. Q22. Provide two (2) principles of cultural safety that you would find helpful when working in this setting. Q23. Provide a brief discussion on what mental health and well-being means. ( max 70 words) Q24. Identify four (4) social determinants for positive mental health. 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 12 of 14 Document1 Q25. Identify five (5) physiological indicators for stress? 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 13 of 14 Document1 123 TMP E – Assessment Template – Written v1.5 (04/11/2020) Page 14 of 14 HLT54121 Diploma of Nursing HLTENN037/038 Clinical Assessment and Care Planning cluster Assessment Task 1 (AT1): APA References Guide – October 2022 ASSIGNMENT REFERENCES GUIDE Resources outlined in this guide are: E Books in the ClinicalKey for Nursing database (student login required) Free access websites/website documents (no student login required – follow the relevant weblinks on p. 4 of this guide). INSTRUCTIONS Access Clinical Key for Nursing • Access the ClinicalKey for Nursing database from the TQ Library Network website page • Visit the TAFE Queensland Library Network – Nursing Subject Guide and watch the video tutorial for how to access and use the Clinical Key for Nursing database. APA Referencing • Bookmark the full TQ Library Network APA Referencing Guide – available HERE • Use APA 7th edition academic referencing and follow the correct two-part format to include: o A citation for every question (as shown in the table below) o A full Reference list (as shown on page 4 of this guide) ASSIGNMENT REFERENCES Q. No. SOURCE IN-TEXT CITATION Tabbner’s Nursing Care 1 Chapter: Nursing process: Framework Section: An overview of the nursing process (Koutoukidis & Stainton, 2021). Tabbner’s Nursing Care 2 Chapter: Nursing care across the lifespan: Conception to late childhood Section: Growth and development (Koutoukidis & Stainton, 2021). Tabbner’s Nursing Care 3 Chapters: Nursing care across the lifespan: 4 chapters covering Conception to Older Adult (Koutoukidis & Stainton, 2021). Tabbner’s Nursing Care 4 Chapter: Nursing care across the lifespan: Conception to late childhood Sections: Factors influencing growth and development (Koutoukidis & Stainton, 2021). Tabbner’s Nursing Care 5&6 Chapter: Nursing in the acute care environment Sections: The family ©TAFE Queensland GC 2022 (Koutoukidis & Stainton, 2021). HLT54121: HLTENN037/038 AT1 References – October 2022 v2 Page 1 of 4 HLTENN037/038: AT1 References Guide Q. No. SOURCE IN-TEXT CITATION Potter and Perry’s Fundamentals of Nursing 7 8 Chapter: Enabling cultural safety Section: Nursing in Australia Nursing and Midwifery Board of Australia Code of Conduct (Cox et al., 2021). (Nursing and Midwifery Board of Australia, 2018). Principle 3.2 Tabbner’s Nursing Care 9-13 (Koutoukidis & Stainton, 2021). Chapter: Vital sign assessment Tabbner’s Nursing Care 14 OR 14 Chapter: Nursing assessment and management of endocrine health Section: Monitoring blood glucose Diabetes Australia Blood glucose monitoring (Koutoukidis & Stainton, 2021). (Diabetes Australia. n.d.) Tabbner’s Nursing Care 15 Chapter: Nursing assessment and management of neurological health Section: Neurological assessment (Koutoukidis & Stainton, 2021). Tabbner’s Nursing Care 16 Chapter: Promotion of health and wellbeing: Nutrition (Koutoukidis & Stainton, 2021). Section: Energy requirements 16 Heart Foundation (Heart Foundation, 2022). Body Mass Index Tabbner’s Nursing Care 17 Chapter: Nursing assessment and management of neurological health Section: Neurovascular assessment (Koutoukidis & Stainton, 2021). Potter and Perry’s Fundamentals of Nursing 18 Chapter: Undertaking a focused assessment: Physical assessment of body systems Section: Gastrointestinal system (Douglas, 2021). Potter and Perry’s Fundamentals of Nursing 19a Chapter: Undertaking a focused assessment: Physical assessment of body systems Section: Integumentary system ©TAFE Queensland GC 2022 (Douglas, 2021). HLT54121: HLTENN037/038 AT1 References – October 2022 v2 Page 2 of 4 HLTENN037/038: AT1 References Guide Q. No. SOURCE IN-TEXT CITATION Tabbner’s Nursing Care. 19b Chapter: Maintenance of health: Hygiene and comfort care Section: Nursing observations of the skin (Koutoukidis & Stainton, 2021). Tabbner’s Nursing Care 20 Chapter: Nursing assessment and management of pain Section: Assessing pain (Koutoukidis & Stainton, 2021). Tabbner’s Nursing Care 21 Chapter: Nursing assessment and management of pain Section: Nursing interventions for an individual experiencing pain (Koutoukidis & Stainton, 2021). Potter and Perry’s Fundamentals of Nursing 22 23 & 24 Chapter: Enabling cultural safety Section: Cultural safety (Cox et al., 2021). Potter and Perry’s Fundamentals of Nursing Chapter: Managing mental health and wellbeing Sections: Introduction; Mental health and wellbeing (Barkway, 2021). Potter and Perry’s Fundamentals of Nursing 25 Chapter: Managing mental health and wellbeing Sections: Box 35.5 ©TAFE Queensland GC 2022 (Barkway, 2021). HLT54121: HLTENN037/038 AT1 References – October 2022 v2 Page 3 of 4 HLTENN037/038: Written Assessment – AT1 Reference List References Barkway, P. (2021). Managing mental health and wellbeing. In J. Crisp, C. Douglas, G. Rebeiro, & D. Waters (Eds.), Potter and Perry’s fundamentals of nursing (6th ed., pp.1336-1360). Elsevier. Cox, L., Taua, C., Drummond, A., & Kidd, J. (2021). Enabling cultural safety. In J. Crisp, C. Douglas, G. Rebeiro, & D. Waters (Eds.), Potter and Perry’s fundamentals of nursing (6th ed., pp.49-83). Elsevier. Diabetes Australia. (n.d.). Blood glucose monitoring. https://www.diabetesaustralia.com.au/living-withdiabetes/managing-your-diabetes/blood-glucose-monitoring/ Douglas, C. (2021). Undertaking a focused assessment. In J. Crisp, C. Douglas, G. Rebeiro, & D. Waters (Eds.), Potter and Perry’s fundamentals of nursing (6th ed., pp.372-415). Elsevier. Heart Foundation. (2022, September 14). What’s your body mass index (BMI)? Retrieved November 13, 2022, https://www.heartfoundation.org.au/bmi-calculator Koutoukidis, G., & Stainton, K. (2021). Tabbner’s nursing care (8th ed.). Elsevier. Nursing and Midwifery Board of Australia. (2018). Code of conduct for nurses https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx ©TAFE Queensland GC 2022 HLT54121: HLTENN037/038 AT1 References – October 2022 v2 Page 4 of 4