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NCP106 Nursing care plans – Assessment 1 Part A Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Introduction Within the health care system, Enrolled Nurses (ENs) work in a collaborative multidisciplinary team to ensure that the individual health care needs of their clients are identified, and a plan of holistic care is established early. This ongoing process starts during the admission of a client, and continues to be reassessed and evaluated for effectiveness for as long as they need care. Assessing the physical, mental and emotional health status of clients on admission can reduce the risk of adverse events, and assist to identify any specific individual needs that will make treatment. This assessment provides you with an opportunity to demonstrate how knowledge of a client’s health status and treatment outcomes can ensure their treatment is appropriate, holistic and person-centred care. Summary The case study is based on a client admitted to your ward. You will need to consider the health status of the client, and the information provided regarding his clinical presentation in order to understand what is needed to support him to make informed decisions relating to his care, and to provide Person Centred care. In your answers, you should apply an understanding of Nursing Diagnosis, nursing assessments and analytical thinking and assessment. Use medical terminology where appropriate and apply directional terms when referring to nursing interventions. Task Instructions Before attempting your assessment, please refresh your knowledge of Mr George McFarlane and his underlying health concerns by first watching the video provided in Blackboard. http://www.kaltura.com/tiny/3z0xh. Once you have reviewed the video, you will then be able to consider the assessment scenario below where Mr McFarlane has a new admission to hospital following an unwitnessed fall at home. To complete Assessment 1, Part A, provide your responses to the questions on the Assessment Response Template below. These short response questions are based on the information received in the unwitnessed fall case study scenario below. Your responses must be typed into the spaces provided beneath each question, and the whole document and associated charts must be submitted to Blackboard as your response to Part A. Assessment 1, Part A, CASE STUDY - BRIEF Course HLT54115 Diploma of Nursing Subject Code and Title NCP106 Nursing care plans Unit(s) of Competency HLTENN004 Implement, monitor and evaluate nursing care plans Performance criteria, Knowledge evidence and Performance assessed PC: 1.1, 1.2, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 3.1. PE: 1, 3. KE: 1, 2, 3, 4, 7, 8. Title of Assessment Task Assessment 1, Part A: Case Study Type of Assessment Task Short Response Length As indicated in each question Submission Due by the end of Module 4.1 (Week 7) http://www.kaltura.com/tiny/3z0xh NCP106 Nursing care plans – Assessment 1 Part A Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Nursing care Plan, Sago Chart, Abbey Pain Chart, Waterlow Scale/ Braden Scale, Falls Risk Assessment Chart required for Assessment 1, Part A, will be provided via Blackboard. These questions must be answered in full. When responding to the questions, please pay attention to the entire question being asked, as well as the prescribed word count. You are required to use the correct medical terminology when answering all questions and are also expected to refer to your assessment charts. Provide nursing rationales for each nursing intervention. You will be assessed on your responses and will be deemed as either satisfactory or not satisfactory. ALL your responses must be marked as satisfactory in order to pass the assessment. If your assessment is not deemed satisfactory, you will re-assessed as per the THINK Education Assessment Policy for Vocational Education and Training (VET) v.4 (04 June 2018), before being awarded a Non Satisfactory mark for the assessment and the unit. Submission Instructions Submissions for Assessment 1, Part A - will be open from the beginning of Module 1.1 until the due date, which is 23:55hrs AEST/AEDT Sunday of Module 4.1 (Week 7). Submit your final response via the Assessment link in the main navigation menu in the NCP106 subject page. The facilitator will provide feedback via the Grade Centre in the Blackboard portal. Feedback explaining the rationale for your grade can be viewed in My Grades. Assessment Process • All items must be submitted by the due date. • All items must be satisfactorily answered / addressed / completed in order for you to achieve a “Satisfactory” outcome for this assessment. • Please note that this is one assessment from the range of assessment tasks you will complete. You must complete all assessment tasks in this subject. Please refer to your subject outline for information on the other assessment tasks. • Clear, constructive and accurate feedback will be given to you on your results and performance. • The assessment items you submit will be retained by the college as evidence of your performance. College Policies and Procedures relating to assessments, and associated forms, are available via http://www.think.edu.au/studying-at-think/policies-and-procedures http://www.think.edu.au/studying-at-think/policies-and-procedures NCP106 Nursing care plans – Assessment 1 Part A Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Scenario – Mr George McFarlane Mr George McFarlane is a 53 year old Caucasian male, who presented to the Emergency Department (ED) by ambulance at 21:30hrs on Saturday evening, after sustaining an unwitnessed fall at home. On his wife’s arrival home, Mrs McFarlane found her husband on the floor and called the ambulance. Mr McFarlane is experiencing pain in his left (L) knee and is unable to weight bear. He states he is feeling dizzy and unstable when attempting to stand upright. It is unclear if he hit his head in the fall as he states, “I felt dizzy when going to the bathroom and I think I blacked out”. Mr McFarlane’s past Medical History (PMHx) includes: • Type ll Diabetes (T2DM) requiring close management • Osteoarthritis (OA) in left Knee • Peripheral Vascular Disease (PVD) • Chronic Obstructive Pulmonary Disease (COPD) • Obesity Social History (SHx): • Second marriage • Not Self-sufficient, requires assistance for activities of daily living (ADLs). • Occupation Long Haul truck driver • Alcohol (ETOH) usage on a regular basis • Smoker, averages 15/20 cigarettes per day • Often consumes take away/ fast food diet as away from home regularly • Has a 26 year old son with several social and mental health issues Mr McFarlane is 135kg and 170cm in height. An x-ray of the (L) Knee shows significant advancement of OA, requiring further investigation. He rates his pain score as currently 8/10, Endone 10mg is prescribed and administered orally at 22:10hrs, with little effect. Neurovascular observations are commenced and his Glasgow Coma Scale (GCS) score is currently 15. Bloods have been taken including: Troponin levels, Full Blood Count (FBC), Cholesterol levels, Liver function Tests (LFT`s), Electrolytes, Urea & Creatinine (EUC) levels, and C – reactive protein (CRP). An Electro-cardiograph (ECG) was taken, and is NAD (no abnormalities detected), ruling out a cardiac issue causing the fall. A lung function test, and further investigations of OA in (L) knee also need to be arranged. Referrals for the Physiotherapist, dietician, social worker, diabetic educator and endocrinologist are to be arranged via eMR (electronic medical records). Current vital signs: Respiratory Rate (RR): 17, SpO2: 93% on room air (RA), Blood Pressure (BP): 150/100, Heart Rate (HR): 99, Temperature: 37.9 oC, GCS: 15. Further orders include: • Regular pain relief as charted • 2/24 Vital signs • 2/24 Neurological observations • 2/24 Neurovascular observations on L) leg • Non weight bearing on L) Leg • Full assistance with ADL`s • Strict FBC (Fluid balance Chart) • TED stockings to be applied • Waterlow score to be assessed NCP106 Nursing care plans – Assessment 1 Part A Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Mr McFarlane was transferred to the Medical/Surgical ward at 07:30hrs the next morning. You have received handover for him and are required to complete the following. Question 1 Referring to the information provided in Mr McFarlane’s case study, write the nursing admission notes, using appropriate medical terminology and a holistic approach. Complete the admission notes on the template provided below. Ensure notes contain relevant information, meet legal requirements and that correct medical terminology is used. Also document the admissions observations on the SAGO Chart. To finalise this question, you must complete the Client Admissions form by documenting the client’s history, your observations of the client and the plan of care for Mr McFarlane. NAME: Mr George McFarlane ADDRESS: 23 Sunset drive, Homerville. 2300 GP: Dr Geoff Waterson MEDICARE NO. 0096723142 #1 DATE: Exp: 2024 AGE ON ADMISSION: GENDER: RELIGION: ETHNICITY: ALLERGIES: Nil Known LIFESTYLE PATTERNS: COPING MECHANISMS: SOCIAL: CURRENT HEALTH PRACTICES/NEEDS: ADL ASSESSMENT: DIET: OUTPUT: MOBILISATION: HYGIENE: FAMILY CONCERNS AND NEEDS RE: CLIENT ADMISSION OBSERVATIONS: T:____ HR: ____ R: ____ BP: ____ SpO2: _____ HEIGHT: ____ WEIGHT: ____ BMI: ____ NURSING NOTES: (sign off with name, signature and delegation at the end of the notes) History: NCP106 Nursing care plans – Assessment 1 Part A