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APH102 Assessing physical health status – Assessment 2 Response Template ASSESSMENT 2 - Response Template Student Name Date Course HLT54115 Diploma of Nursing Subject Title Assessing physical health status Unit of Competency HLTAAP002 Confirm physical health HLTENN003 Perform clinical assessment and contribute to planning nursing care Performance Criteria, Knowledge and Performance Evidence Assessed PC: HLTAAP002 = 1.1, 1.2, 1.3, 1.4, 2.1, 2.2, 2.3, 3.1, 3.2, 3.3, 3.4 HLTENN003 = 1.2, 1.3, 1.6, 1.7, 1.8, 1.9, 2.1, 2.2, 2.3, 2.4, 3.1, 3.2, 3.3, 4.1, 4.2, 4.3, 4.4 PE: HLTAAP002 = 1 HLTENN003= 1, 2, 4 KE: HLTAAP002 = 1, 2b, 4a, 4b, 5, 7a, 7b, 7c, 7d, 7e, 7f, 7g, 8, 9, 10, 11a, 11b HLTENN003 = 1, 2a, 2b, 2c, 2d, 3, 4, 5, 6, 7, 8, 9, 11, 12a, 12b, 12c, 12d, 12e, 12f, 12g, 12h, 12i, 12j, 12k, 12l, 13, 14, 15, 16, 17, 18, 19, 20 Title of Assessment Task Assessment 2 For this assessment, you must read two case studies then and answer the questions below each one. When responding to the questions, please pay attention to the entire question being asked, as well as the prescribed word count. And, use the correct medical terminology when answering all questions. Scenario 1 Mrs Yu Yan McFarlane (questions 1-7 refer to this scenario) Mrs Yu Yan McFarlane is a 38-year old female, who had an abdominal hysterectomy two (2) days ago. Yu Yan is on four (4) hourly observations. The most recent recorded observations were: · Temperature 36.5 °C, · Respirations 22, HR 110, · BP 135/80mmHg and · SpO2 98%, on room air · Reported 7/10 abdominal pain Mrs McFarlane has received opioid analgesia for two (2) days and has reported that she has not opened her bowels. She requires assistance to perform ADL’s (Activities of daily living), due to her pain and has expressed embarrassment at being assisted in the shower. She shared in confidence that she was concerned about becoming menopausal. Her mother experienced a lot of emotional distress when she went through menopause, and her body changed as well. Yu Yan suffers from anxiety and has a very poor self-image. She already finds it difficult to adjust to her body, and now that she is no longer fertile she is becoming quite anxious about what might happen to her when menopause begins. Mrs McFarlane feels embarrassed when undressing in front of nursing staff. Mrs McFarlane admits to having difficulty identifying with her own sexuality as a result of the changes she is going through and has said it is causing issues with her husband. Yu Yan lives with her 70-year-old mother, Fei Hong, her husband George and their children; three-year-old twins and Yu Yan’s 17-year-old son Jason from a previous relationship. She is sceptical of the support she might be able to receive from you regarding her body changes, as she doesn’t feel that a healthcare team can do anything to stop them, so she feels quite pessimistic about any interventions. Question 1 Based on the information received in the case study, you need to consider how best to plan appropriate care for Yu Yan. Using the template below, plot out a care plan for Yu Yan taking into account the information provided. This requires you to: · Specify four (4) nursing diagnoses or risk factors associated with the client’s health variations · Record at least two (2) nursing interventions that could be applied for each diagnosis · Specify at least one (1) community support service that may be able to support your suggested interventions · Clarify how your planned intervention reflect the client’s interests and physical, emotional and psychosocial needs · Note at least one (1) expected outcomes that you would hope for as a result of each intervention. Nursing diagnosis Planning - (Nursing intervention) Community support service Link to personal needs Expected Outcome Question 2 Mrs. McFarlane has confided that she has had trouble adjusting to her body image now that she is no longer fertile. · In 20 words, suggest how Yu Yan’s values and attitudes regarding health care, and the issues/anxieties she has may impact on a timely discharge. · Specify what developmental stage of adulthood Yu Yan is going through, and list two (2) additional Physiological changes people go through at that stage. · Also, list two (2) other stages of adulthood and for each, specify two (2) psychosocial or psychological changes that might be experienced by people going through them. Response: Question 3 Mrs. McFarlane has expressed embarrassment at needing assistance with her ADL’s (Activities of daily living) due to her poor self-image. This implies she may need support emotionally as well as physically. In 50 words, explain: · What a wellness approach to health is · How it may benefit Yu Yan given her current anxieties · How you would clarify with Yu Yan that this approach would align with her needs · And, provide one (1) community support agency that may be able to assist you to when facilitating a wellness approach to care Response: Question 4 Yu Yan’s situation is common amongst many women her age. Additionally, it may also be influenced by how she has grown and developed, and what her genes are. · Specify four (4) stages of human growth and development · Then, in 20 words, explain how genetics and environment may impact a person’s own development Response: Question 5 As soon as clients present and are admitted into care, the healthcare team also starts planning what is needed for discharge. List a minimum of six (6) requirements that might need to be confirmed for Yu Yan before Yu Yan is discharged, and explain why they are needed, using 10 words for each. Response: Question 6 Yu Yan has 3-year-old twins at home, whose developmental needs differ from hers greatly. It is important that you understand these needs when considering the type of care that Yu Yan could be provided after discharge, as her wellbeing will affect theirs. Describe the developmental stages of childhood by addressing each point below: · List five (5) physical growth, psychosocial, cognitive and motor development needs of toddlers and pre-school and school aged children · List five (5) physical growth, cognitive and motor development needs of infants 0-12 months · Explain in 20 words, the role of play in a child’s development · Explain in 20 words, the impact that hospitalisation of a child can have on the child and family Response: Question 7 Yu Yan also has a 17-year-old son, Jason. His stage of development is different from both hers and the twins. In 30 words, describe the developmental stages of adolescence and list four (4) common health issues or psychological concerns that adolescents face. Response: Scenario 2: Mrs Fei Hong (Questions 8-13 refer to this scenario) On Sunday at 1000hrs, you are assigned to admit a new client to your ward. Fei Hong is a 70-year-old female who was admitted to your ward this morning, following a fall at home. On admission, her daughter Yu Yan is in attendance. Fei Hong has sustained significant bruising and swelling to her right hip and shoulder with a large skin tear to her right forearm. She did not sustain any fractures. She is admitted for pain relief, dressings to her forearm, and a physiotherapy review. However, on assessment Fei Hong has bony prominences on her hips and pelvis, and is at risk of developing pressure areas. Yu Yan has requested an interview with the doctor to determine if her mother needs any extra care at home, as Fei Hong is beginning to show signs of Dementia according to her daughter. Fei Hong generally eats a small, but nutritious diet at home that includes all food groups, but which is predominantly Asian cuisine. Fei Hong has reported no urinary issues and takes Metamucil daily to prevent chronic constipation. She can shower and dress independently but requires supervision and prompting at times, due to early signs of Dementia. She had been mobilising independently prior to his fall. She will need to be assessed by a physiotherapist for a walking aid. Medically, Fei Hong has some hearing and sight impairment, and wears glasses and bilateral hearing aids, but is on no medications. Socially, she lives with her daughter Yu Yan, son-in-law George and their children; three-year old twins and Yu Yan’s 17-year-old son Jason from a previous relationship. Yu Yan cares for her mother and her three (3) children and has no community support for her mother. Fei Hong, has no other extended family, as she immigrated to Australia 16 years ago to help her daughter raise her son, she speaks little English and is Buddhist. She states that her strong faith and her daughter help her cope with her ageing process. Fei Hongs observations on admission are: · Temp 36.1, BP 105/68, · Respirations 18, · Pulse 64, · Height: 156cm and Weight: 46kg. · Fei Hong is thin, with a BMI of 19 Question 8 Referring to the information provided in Fei Hong’s case study, write the nursing admission notes, using appropriate terminology and a holistic approach. Please complete the admission notes on the template provided below. Ensure notes meet legal requirements and use correct medical terminology. NAME: ADDRESS: GP: MEDICARE NO. DATE: AGE ON ADMISSION: GENDER: RELIGION: ETHNICITY: ALLERGIES: LIFESTYLE PATTERNS: COPING MECHANISMS: SOCIAL: CURRENT HEALTH PRACTICES/NEEDS: ADL ASSESSMENT: DIET: OUTPUT: MOBILISATION: HYGIENE: FAMILY CONCERNS AND NEEDS RE: CLIENT ADMISSION OBSERVATIONS: T____ P: ____ R: ____ BP: ____ HEIGHT: ____ WEIGHT: ____ BMI: ____ NURSING NOTES: (sign off with name, signature and delegation at the end of the notes) History: Assessment: Admission Plan: Name: ___________________ Signature _______________ Question 9 Another Nurse has drafted a plan of care for Fei Hong. Respond to the questions below based on the scope of your work as an enrolled nurse, using 20 words for each: · How would you confirm that this plan reflects the needs of Fei Hong and her family? · If this care