Allergic to Penicillin Social History

ASSESSMENT 1 Response Template
Student Name answer here...
Date answer here...
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: 1.1, 1.2, 1.3, 1.6, 1,7, 2.1, 2.2, 2.1, 2.3, 2.4, 3.1, 4.1
PE:
HLTAAP002: 1
HLTENN003: 1, 2
KE:
HLTAAP002: 1, 2a, 2c, 3a, 3b, 3c, 3d, 3e, 3f, 3g, 3h, 3i, 3j, 3k, 3l, 3m,
4a, 4b, 5, 6, 11a, 11b
HLTENN003: 1, 14, 20
Title of
Assessment Task Assessment 1
Part 1: Short Answer Questions
For this assessment, you must watch the case study scenario 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 will come from what you have covered in
modules 1-3.
Patient Details
 George McFarlane, male, born in Australia, age 53 years.
 Address: 62 Koala Avenue, Belle Hill 2023 NSW
 Medicare Number 654794329 6/1
 Private Health: HCA hospital only
 GP Dr. Wing Lo Chiang
Medical History
 George weighs 118 kg and his height is 180cm.
 He is a current smoker and smokes 15 cigarettes a day which he has done for 30
years.
 He has type 2 diabetes (2 years) and osteoarthritis in his Left knee. He lives a
sedentary lifestyle.
 Takes BGL daily.
 Sees Dr every 6 months.
 Allergic to Penicillin
Social History
 Occupation long haul truck driver.
 Religion Anglican but does not go to church.
 Has a 26-year-old son from a first marriage who has depression and uses illicit drugs,
visits occasionally.
 Has a stepson, Jason aged 17 from his second marriage to Yu Yan whom he married 5
years ago and with whom he lives.
 Yu Yan is of Chinese heritage and speaks English well.
 George and Yu Yan are parents to 3-year-old twins from his current marriage. One
twin has a developmental disorder.
 George is away from home a lot on the road travelling for work to pay the bills.
 George is often isolated from his family and friends, due to his occupation. He
telephones his wife daily when away.

 George often watches TV and drinks a few beers a night to cope with stress.
Context
George has come into hospital today as his BGL is higher than normal at 15mmols. 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, the nurse takes a set
of vital signs and completes the admission form. A urinalysis is also taken.
TASK Assessment Criteria
Question 1 In relation to the case study video scenario you have just watched,
and the patient history you have, please complete the admission
form provided. You must complete every section that is blank. Some
sections are prefilled for you.
ADMISSION NOTES
(provide an overview
of the patient’s
situation)
George is a diabetic tye two patient patient taking BLG dairy. He also
has a Osteoarthritis to his left knee. He is also allergic to penicilin. He
is addicted to smoking for over 30 years. Came complaining of
headache, increased heart thirst ,increased urine volume. .
NAME: George Mc Farlane..
ADDRESS: 62 Koala Avenue. Bille Hill 2023NSW .
GP: .Dr. Wing Lo Chiang .
MEDICARE NO. 654794...
DATE: 28/03/2020
AGE ON ADMISSION: 53..
GENDER: Male...
RELIGION: Christian.
ETHNICITY: Australian.
ALLERGIES: Penicillin
LIFESTYLE PATTERNS: Diabetic and smokes regularly
COPING
MECHANISMS:
Takes BGL...
SOCIAL: Watches TV drinks a few beers each night.
Lives with his wife and children.
CURRENT HEALTH
PRACTICES / NEEDS: Takes BGL daily. Sees Dr 6 monthly
ADL ASSESSMENT: DIET: NONE.
URINARY AND BOWEL PATTERNS: Has a high Sg
MOBILISATION: answer here...
HYGIENE: answer here...
FAMILY CONCERNS
AND NEEDS RE:
CLIENT:
..NONE.
ADMISSION
OBSERVATIONS:
T37 answer here...
P: 110bpm answer here...
RR: 26 answer here...
BP: 170/90 answer here...
SaO2: 97% .
HEIGHT: 180cm.
WEIGHT: 118.kg..
BMI: 65...

CURRENT
MEDICATIONS:
..takes BGL to regulate the blood sugar.
NURSING NOTES:
Below, you should summarise the points from the video and provide some additional
information on the client’s history, and some notes about your assessment, and an admission
plan (Sign off with name, signature, and delegation at the end of the notes).
New client, Mr. George McFarlane admitted to the ward at 1000.
History: (Provide a sentence or two about the client’s history and current situation – point
form ok).
Assessment: (Provide some points about what was discovered during the health assessment
and discussion. Some are filled out already.)
 During the assessment, it was discovered the patient was dehydrated for losing much
water through the urine..
 Observations, as recorded in admission observations above.
 answer here...
 Reported to the RN.
 ...
Admission Plan: (Provide some points about the actions you recommend taking from this
point. Some are filled out already.)
 answer here...
 Provide regular analgesia as charted
 answer here...
 Arrange for the doctor to review Mr. McFarlane.
 the answer here..Te.
Name: ___________________ Signature _______________
TASK Assessment Criteria
Question 2 The nurse has taken Mr. McFarlane'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 Mr. McFarlane's blood pressure is within the normal range.

Response: The normal blood pressure for a healthy individual should be 120/80mmHg or
139/89mmHg in a high range. Reading over 120/80mmHg to 139/89mmHg may be the
abnormal state and one may be considered hypertensive. For individuals below 80 years, the
recommended blood pressure should be below 139/89 mmHg. Above this, one is said to be
hypertensive. McFarlanes is hypertensive as his blood pressure is beyond the normal range
which is 170/90mmHg.
TASK Assessment Criteria
Question 3 As an Enrolled Nurse (EN), explain in 20 words who you should report
your findings to and why, if a client’s measurements are displaying
unusual levels, or you are concerned about the results you have
received?
Response: The nurse should report the findings to the RN who will confirm the findings and
take measures for the unusual levels.
TASK Assessment Criteria
Question 4 In 50-75 words, identify your scope of practice as an EN in this
situation, and list your roles and responsibilities compared to that of a
Registered Nurse (RN).