HLTENN003 Perform Clinical Assessment and Contribute to Planning Nursing Care

Instructions to the student

During this assessment, you will be assessed on your ability to complete the admission and discharge process for a patient under your care, in addition, utilise the information you have obtained to determine the appropriate nursing intervention required by the patient.

To complete this assessment:

1. Read the case study background information on Jack
2. Complete the following six (6) tasks outlined in assessment.

Ensure when you are completing this assessment:

• You use appropriate medical and anatomical terminology
• Your answers are to be referenced using the APA 6^th Edition referencing standard.

Note - Where required, the patient role will be simulated by another class member.  The practical skills component (task 6) outlined in this assessment will take place at a time advised by your educator.

Task 1: Admission process
Using the admission pack provided, you are required to complete the following nursing interventions for Jack as part of his admission process.

1. Admission documentation
2. Blood glucose level
3. Urinalysis
4. Neurological observations
5. Neurovascular observations
6. Progress notes.

Task 2: Care planning

On the care plan form provided, you are to identify a minimum of three (3) actual or potential nursing diagnoses for Jack, then utilising the nursing process - complete a nursing care plan for Jack.

Task 3: Discharge planning

Based on the actual or potential nursing diagnoses you have identified, document using the form provided, what education could be provided to Jack and/or their family/caregivers that would benefit Jack when he is discharged home. You must include a:

• Brief outline of the services provided
• Rationale how this providers services would benefit Jack.

Task 4: Community support services

Using the same document for task 3, identify community support services, or allied health referral that Jack could access on discharge to assist in his ongoing care needs. You are to identify an appropriate service for each of the three (3) actual or potential nursing diagnoses you identified. You will need to include:

• Name and contact information of the service
• Brief outlines of the services provided
• Rationale how this providers services would benefit Jack.

Task 5 – Pathophysiology and understanding the disease
Using the same document that you used for task 3 and 4, include a brief introduction to the disorders / conditions Jack has identified during his admission. Your information must include:

• Pathophysiology of the condition
• Signs and Symptoms of the condition
• Classification of each condition as either acute or chronic
• Current medications Jack takes to manage the condition
• A brief outline of the diagnostic tests used to diagnose the condition.

Task 6 – Practical skills

At a time advised by your educator, you will be assessed on the six (6) practical skills. The six skills you will be assessed on will be conducted against the competency checklists provided in the text book (unless indicated otherwise): Koutoukidis, G. and Stainton, K (2017). Essential enrolled nursing skills for person centred care. 7^th Ed. Sydney: Elsevier Australia and include:

1. Skill 20.4 Measuring Oxygen Saturations – page 66
2. Skill 21.1 Admission and discharge process – page 79
3. Skill 31.3 Urinalysis – page 304
4. Skill 35.1 Performing a neurological assessment – page 343
5. Skill 35.2 Neurovascular assessment – page 350
6. Skill 36.1 Measuring blood glucose – page 355

Resources for this assessment

The following documents/forms to complete these tasks are outlined below (unless indicated otherwise from your educator)

• Task 1 - Admission pack
• Task 2 - Use the care plan attached to this assessment on page 5
• Task 3, 4 and 5 - Use the document provided in this assessment to complete your written responses
• Task 6 - The six skills you will be assessed on will be conducted against the competency checklists provided in the text book (unless indicated otherwise): Koutoukidis, G. and Stainton, K (2017). Essential enrolled nursing skills for person centred care. 7^th Sydney: Elsevier Australia.

Deliverables for this assessment

To gain a satisfactory result for this assessment, you will need to upload all of the following documents below into OpenSpace in one submission.

Your OpenSpace assessment submission is to include:

• Your completed assessment coversheet and your assessment evidence checklist which is attached to this assessment. (Your educator will provide feedback and comments on this checklist and will provide a copy back into OpenSpace once your entire submission has been marked.
• Task 1 - Your completed admissions pack/documentation on Jack.
• Task 2 - Your completed care plan.
• Task 3 - Discharge planning, Task 4 Community support services and Task 5 Pathophysiology and understanding the disease written responses
• Task 6 - Copies of your six practical clinical checklists that you were assessed on.

Case study background information – Jack

Jack is a 42-year-old male who has presented to hospital with exacerbation of his asthma. He is obese, weighing 139kgs and is a Type 2 Diabetic on oral hypoglycaemic medication. He also is complaining of constipation and a sore bottom as he has been mainly chair bound due to his unstable asthma in the last few days.

Jack has a family history of HT and is particularly anxious today due to his dyspnoea (difficulty in breathing) and worsening state.

His current medications include:

• Salbutamol Inhaler 2 puffs 4/24hrly prn
• Pulmicort turbohaler 2 puffs BD
• Metformin 1gm BD
• Gliclazide 2.5mg mane

You are the admitting nurse today and are responsible for his nursing assessment and collection of his admission data. His initial baseline observations are:

• * BP 165/95
• * Pulse 98
• * Respiratory rate 20
• * Temperature 36.5
• * Oxygen Saturation 96%

Task 2: Care planning - On the care plan below, you are to identify a minimum of three (3) actual or potential nursing diagnoses for the resident, then utilising the nursing process, complete a nursing care plan for this resident.

Task 3 Discharge planning - Based on the actual or potential nursing diagnoses you have identified, document using below, what education could be provided to Jack and/or their family/caregivers that would benefit Jack when he is discharged home. You must include a brief outline of the services provided and rationale how this providers services would benefit Jack.

Task 4 - Community support services - Identify community support services, or allied health referral that Jack could access on discharge to assist in his ongoing care needs. You are to identify an appropriate service for each of the 3 actual or potential nursing diagnoses you identified. You will need to include: Name and contact information of the service, brief outline of the services provided, rationale how this providers services would benefit Jack.

Task 5 - Pathophysiology and understanding disease - Include a brief introduction to the disorders / conditions Jack has identified during his admission. Your information must include:Pathophysiology of the condition, signs and symptoms of the condition, classification of each condition as either acute or chronic, current medications Jack takes to manage the condition and a brief outline of the diagnostic tests used to diagnose the condition.

Assessment Evidence Checklist
The assessment evidence checklist is a record of your assessment activity outcome. Once you have submitted all six tasks into OpenSpace, your educator will provide feedback and comments on this checklist and will provide a copy back into OpenSpace once your entire submission has been marked.

You have two attempts to complete the assessment. If you need to re-attempt the assessment task your educator will give you clear and direct feedback with revised submission dates if required. Note: If all six (6) tasks are not uploaded into Openspace, your submission will be marked as Not Yet Satisfactory.