Assessing physical health status

Assessment 1 – Response Template

Student Name

Date

Course

HLT54115 Diploma of Nursing

Subject Code and Title

APH102 Assessing physical health status

Unit(s) of Competency

HLTAAP002 Confirm physical health

HLTENN003 Preform clinical assessment and contribute to planning nursing care

Performance criteria, Knowledge evidence and Performance 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, 4.1, 4.2,

4.4

PE:

HLTAAP002: 1

HLTENN003: 1.

KE:

HLTAAP002: 1, 2a, 2c, 3a, 3b, 3c, 3d, 3e, 3f, 3g, 3h, 3i, 3j, 3k, 3l, 3m, 4a, 4b, 5, 6, 7f, 7g, 8, 11a, 11b

HLTENN003: 1, 8, 9, 14, 18, 20

Title of Assessment

Assessment 1: Case Study

Type of Assessment

Short Response

Length

As indicated in each question

Submission

Due by the end of Module 3.2 (Week 6)

Assessment 1: Short answer questions

For this assessment, you must watch the case study video, review the scenario provided and respond to the questions below. Some of the information you need will be in the video and some will be in this overview, while the majority of the knowledge you will need to answer these questions, will come from what you have learnt in modules 1 – 3 of this subject.

Scenario – Mr George McFarlane

I: Mr George McFarlane is a 53year old Male.

S: George has presented to hospital today as his BGL is higher than normal at 15mmol/L. He has a headache, feels lethargic, is passing an increased volume of urine and has increased thirst. He is also short of breath when walking and exercising. On admission, a set of vital signs and a urinalysis has been taken.

B: George’s past Medical History (PMHx) include:

Type ll Diabetes needing close management. Records BGL daily

Osteoarthritis in L) Knee

Allergy to Penicillin

Social History (SHx):

Married for 5 years to Yu Yan, who is of Chinese heritage, she speaks English well

Has a 26 year old son from a previous marriage, who has depression and uses illicit drugs. He visits occasionally.

Lives with his wife and 3 year old twins, from his current marriage. One twin has a developmental disorder. His 17 year old step son also lives with the family.

Occupation: Long Haul truck driver, often isolated from family and friends as on the road and away from home due to work. Speaks to wife daily when away.

ETOH (Alcohol) usage on a regular basis

Smoker, averages 15 cigarettes per day

Often consumes take away/ fast food diet as away from home regularly

Sedentary lifestyle, often watches TV to cope with stress. Little to no exercise

A: George is 118kg and 180cm in height. Current vital signs Resp 26, O2 Sats 97% on room air (RA), BP 170/90, HR 110, Temp 37.

R: Admit George to the Med/Surgical ward at 1000hrs. For review by the doctor. Provide regular analgesia

Question 1

Referring to the information provided in George’s case study and the video you have watched, complete the nursing admission form, on the template provided below, using appropriate medical terminology. Ensure the documentation meets legal requirements.

NAME:

Mr George McFarlane

ADDRESS:

62 Koala Ave, Belle Hill 2023. NSW

GP:

Dr Wing Lo Chiang

DATE:

AGE ON ADMISSION:

GENDER:

Male

ALLERGIES:

PREVIOUS MEDICAL HISTORY:

LIFESTYLE PATTERNS:

ADL ASSESSMENT:

DIET:

MOBILISATION:

HYGIENE:

ELIMINATION:

ADMISSION OBSERVATIONS:

T____ P: ____ RR: ____ BP: ____ BGL: _____SpO2: ______

HEIGHT: ____ WEIGHT: ____ BMI: ____

Current medications

Family concerns and needs re: client

NURSING NOTES:

Reason for presentation to hospital:

Admission Plan:

Name: ___________________ Signature: _______________ Date: ____________

Question 2 (50 words)

The admission nurse has taken George’s blood pressure and it is 170/90mmHg. In 50 words, list the parameters for normal blood pressure and the range for hypertension. Include in your answer whether George’s blood pressure is within normal limits.

Reference required.

Response:

Question 3 (word count 20 words)

As an Enrolled Nurse (EN), explain in 20 words, who you should report your assessment findings to and why, if a client’s measurements are displaying unusual levels, or if you are concerned about the results you have received.

Hint: refer to the Nurses and Midwifery Board of Australia (NMBA) standards for practice for EN.

Response:

Question 4 (word count 50 – 75 words)

In 50 – 75 words, identify your scope of practice as an EN in the above situation. List your roles and responsibilities compared to that of a Registered Nurse (RN).

Hint: refer to the Nurses and Midwifery Board of Australia (NMBA) standards for practice

Response:

Question 5 – (word count 30 words)

George’s other observations are noted below. In 30 words, indicate the normal ranges for temperature, pulse and respirations and state whether George’s observations are within normal range.

Current observations:

Respirations at 26 breaths per minute.

Temperature 37C

HR 110 beats per minute (bpm).

SpO2 97% on room air.

References required

Response:

Question 6 – (word count 20 – 30 words)

George has provided a urine sample. The urine sample is clear. When attending a urinalysis, you note the specific gravity (SG) is 1005 and the ph. is 6, ketones + and glucose ++. State the normal parameters for these readings and identify the abnormal results. Specify what condition George’s abnormal results may relate to. (Hint: consider George’s medical history)

References required

Response:

Question 7

George has a significant medical and social history. Name three (3) factors (actual or potential) that could have contributed to his current medical issues.

Response:

Question 8

Other than an EN/ RN, name three (3) health care professionals found in a hospital setting that you might be able to refer George to for assistance with his health variations. For each professional, in 20 words, state how they could contribute to George’s wellness.

Reference required.

Response:

Question 9

Below are the health conditions George has. For each condition, name the body system, which relates to it and specify what that system is responsible for doing.

High blood pressure

Type 2 diabetes

Obesity

Shortness of breath on exertion

Osteoarthritis left knee

Reference required

Response:

Question 10 (word limit 100 words)

In 100 words, discuss the pathophysiology of Type 2 Diabetes in relation to the body system involved. In your response, specify the body system affected and what has happened to the cells to cause this condition.

Reference required

Response:

Question 11 (word limit 300 words)

George is currently prescribed the following medications;

Metformin 500mg, 1 (one) tablet daily

Panadol Osteo 665mg, 2 tablets 3 times per day as required (for the osteoarthritis in his left knee)

Refer to your readings in module 3.2, and in your own words describe;

The first pass effect and bioavailability

The 4 processes involved in pharmacokinetics

Two (2) conditions/ disorders that will affect the process of metabolism and excretion of medications

Reference required

Response:

Question 12 (word limit 75 words)

George’s wife Yu Yan is originally from China. If George were to become unresponsive you would need to communicate and respectfully interact with her. In 75 words, explain your understanding of the NMBA’s code of conduct in relation to culturally safe and respectful behaviour.

Response:

Question 13

George is due for discharge. The medical officer has increased his Metformin to 850mg BD and has advised George to follow up with his GP in one week. The diabetic educator and dietician will continue to review George monthly on discharge. You have notified Yu Yan who will collect George before 10am. Both George and Yu Yan are aware of follow up appointments and have no concerns relating to the ongoing treatment for George. George requires a medical certificate for 2 weeks and you have removed his IV cannula.

Complete the discharge summary on the template provided below, to include the information provided to George and his wife, using appropriate medical terminology. Ensure the documentation meets legal requirements.

Discharge Summary

NAME:

Mr George McFarlane

ADDRESS:

23 Sunset drive, Homerville. 2300

GP:

Dr Geoff Waterson

Admission Date:

Discharge Date:

GENDER:

ALLERGIES:

PREVIOUS MEDICAL HISTORY:

Medications on discharge:

Transport arrangements:

Invasive devices removed?

Medical certificate required?

Personal items returned to client?

NURSING NOTES:

Client/ family concerns re discharge

Summary of presentation to hospital:

Follow up appointment after discharge:

Name: ___________________ Signature: _______________ Date: ____________

Question 14

Below is a table listing a range of common diseases, disorders and their symptoms. Using the list of body systems below, specify,

In the first (1st) column, identify which body system is affected by the associated disease or disorders. (Each system is used once)

In the second (2nd) column, note the function of the specified body system

In the third (3rd) column list one (1) other body system that interacts in close collaboration with the body system identified in column 1.

For example; digestive systems works in close collaboration with the endocrine system

Nervous system

Cells, tissues and organs

Endocrine system

Musculoskeletal system

Reproductive system

Immune system

Digestive system

Lymphatic system

Respiratory system

Integumentary system

Urinary system

Special senses

Cardiovascular system

Common disease

Body system affected

Body systems function

Other body system interaction

Splenomegaly: Enlargement of the spleen, usually as a result of infection, disease or malignancy.

Diabetes Mellitus: The complete absence, deficiency or resistance of the Insulin hormone. Manifests as hyperglycaemia (high blood glucose levels in the blood)

Osteomyelitis: An infection usually following surgery or open fractures, causing pain, fever and purulent discharge.

Emphysema: Usually develops from progressive destruction of elastic tissue around the alveoli, causing an inability for them to recoil. Symptoms include a barrel chest and shortness of breath

Basil cell carcinoma: Most likely occurs on sun exposed sites, usually appearing as a shiny nodule and later breaks down to become an ulcer with irregular edges.

Renal calculi: Stones of oxalate and phosphate develop and form in the kidneys. These can cause infections and back/ abdominal pain

Pancreatitis: inflammation of the pancreas. Symptoms include severe epigastric or upper left abdominal pain radiating to the back. Fever, anorexia, nausea and vomiting.

Benign prostatic enlargement: Occurs when hyperplastic nodules form around the urethra, causing obstruction of the flow of urine, resulting in urinary retention

Neoplasms/ Tumours: Rapidly growing masses of tissue that continue to grow after the initial stimulus has ceased.

Labyrinthitis: inflammation/ infection of the inner ear. Can present with nausea, dizziness and/ or hearing deficits.

Myocardial infarction: Unrelenting, severe, crushing chest pain that continues at rest, may often radiate down the left arm.

Acquired immune deficiency syndrome (AIDS): Develops from the human immunodeficiency virus (HIV). Symptoms vary from diarrhoea to lymphoma depending on progression.

Bacterial Meningitis: inflammation of the subarachnoid space, resulting in severe headaches and photophobia.

Question 15

Within the body there are different levels of structural organisation and complexity. Complete the following paragraph about the structural organisation of the body by inserting the words from the bank below into the correct places (the words may be used more than once).

Skeletal

Epithelial

Connective

Cells

Cardiac

Tissues

Organs

Smooth

Systems

Muscle

Nervous

The smallest independent unit of living matter are ______________, which combine to form ___________, and these combine to form _________ that make up the body ________. There are four (4) specialised types of tissues, these include _________, ____________, ___________ and _________. There are three (3) types of muscle tissue, which are __________ muscle tissue, ___________ muscle tissue and ____________ muscle tissue. Together, __________ and ___________ make up the ________ within the body. These _____________ provide the survival needs of the body.

Question 16

Match the anatomical terms to the position that they describe.

Anatomical terms

Answers

Position

Anterior

Middle

Posterior

Below

Lateral

Face down, palms up

Bilateral

Toward the front/ in front of

Superior

Head

Inferior

Inside

Internal

Farthest

External

Above

Proximal

Outside

Distal

Face up, palms down

Cephalic

Toward the back/ in back of

Supine

Side

Prone

Nearest (to the centre)

Medial

Both sides

Peripheral

Outer edges

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