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).

Response: An enrolled nurse works under the supervision of an enrolled nurse and performs physical examination
for the client such as temperature blood pressure.The EN is also responsible for reporting any change of the client
to the RN or the doctor. The EN nurse is also responsible for administering medications, promoting health safety
along with educating the clients on healthy living on the other hand RN nurse supervises and mentors the Enrolled
nurse . Moreover, the RN works in collaboration with the multidisciplinary team for the better outcome of the
patient.
TASK Assessment Criteria
Question 5 Mr. McFarlane's other observations are noted below. In 30 words, indicate the normal ranges for
temperature, pulse and respirations and state whether Mr. McFarlane's observations are within
the normal range.
Current observations:
 Respirations at 26 breaths per minute.
 Temperature 37C
 Pulse 110 beats per minute (bpm).
 SpO2 97% on room air.
Response: The normal respiratory rate for a healthy individual is 12-20 breaths per minute.The normal tempertaute
range is between 36-38C. For a normal pulse rate, it ranges between 60-100 bpm. The normal Oxygen Saturation
levels should range 94-99%, therefore, The patient has an abnormal respiratory rate, a faster pulse rate than
normal. The temperatures are within the range and oxygen saturation rate is also normal...
TASK Assessment Criteria

Question 6 Mr. McFarlane has provided a urine sample. The urine sample is clear. When attending a urinalysis,
you note the sg is 1005 and the ph. is 6 ketones + and glucose ++. In 20-30 words, identify the
abnormal results and specify what condition Mr. McFarlane's abnormal results may relate to.
Response: The specific gravity of urine should range between 1002-1030. If there is a high sg in urine it indicates
there is extra glucose or protein in the urine.It may be also as a result of dehydration. Therefore Mc MCfarlane may
be loosing too much water and his body may be going dehydrated. Being diabetic it could be an indication that his
kidney may not be functioning normally.
TASK Assessment Criteria
Question 7 Mr. McFarlane has significant medical and social history. Name three (3) factors (actual or
potential) that could have contributed to his medical issues.
Response: The patient is obese with 118kg, therefore, it could lead to hypertension or diabetes.
Addicted to smoking 15 cigars per day. He has diabetes type two . He also lives an isolated and sedentary life.
TASK Assessment Criteria

Question 8 Name three (3) health care professionals found in a hospital setting that you might be able to
refer Mr. McFarlane to for assistance with his health variations. For each professional, in 20
words, state their role and how they could contribute to Mr. McFarlane's wellness.
Response: Physician - The physicians are clinical personnel that is responsible for prescribing the recured medicines
to the patients. The physician will help the patient in determining the proper medication that will lower his blood
sugar.
The nutritional Therapist will advise the patient on the food he is required to take to reduce his weight and control
his sugar and inform him of the proper healthy lifestyle for his well being.
A general Practitioner treats chronic diseases such as diabetes and may give preventive measures and educate the
patient on how to avoid cigarette smoking.
TASK Assessment Criteria
Question 9
Below are the health conditions Mr. McFarlane has. For each condition, name the body system,
which relates to it and specify what that system is responsible for doing.
For example, kidney stones relate to the Urinary system, which eliminates waste from the body,
regulates blood volume and blood pressure, controls levels of electrolytes and metabolites, and
regulates blood pH.
 High blood pressure
 Type 2 diabetes
 Obesity
 Shortness of breath on exertion
 Osteoarthritis left knee

Response: High blood pressure is related to the circulatory system where it consists of the heart and the blood
vessels. The heart pulse rate may increase the rate to which blood flows to the blood through blood vessels.
Type 2 Diabetes- When the pancreas is unable to release enough insulin for controlling the blood sugar.
The obesity-The nervous system works to regulate the metabolic rate and homeostasis hence low SNS means a
high weight gain
Shortness of Breath on exertion- Respiratory system consisting of the lungs, larynx, bronchi,and trachea are
responsible for the movement of air in and out of the body.
Osteoarthritis left knee occurs in the body joints or muscle skeleton system. The autoimmune systems attacking
the joints
..
TASK Assessment Criteria
Question 10 In 100 words, discuss the pathophysiology of Type 2 Diabetes in relation to the pathophysiology of
the system involved. In your response, specify the body system affected and what has happened
to the cells to cause this condition.
Response: ..Diabetes type two is a chronic condition due to the body resisting insulin regulation or when the
pancreas is unable to produce insulin responsible for regulating blood sugar. It occurs when the blood glucose is too
high than normal The endocrine system which is the pancreas,liver, pituitary gland and penial gland are al involved
in sugar levels. The condition is characterized by the autoimmune system and destruction of beta cells of the
pancreas hence the pancreas may not produce the insulin required for glucose regulation.
TASK Assessment Criteria
Question 11 Mr. MacFarlane has been taking regular oral pain medication for some time (tablets for the
osteoarthritis in his left knee). Concerning Mr. McFarlane's situation and the way he takes this
medication, specify a factor that might affect therapeutic levels, and explain in 100 words why this
might happen. In your response, consider basic pharmacology, contraindications, and
pharmacokinetics.

Response: Some of the factors that may affect therapeutic levels of the patient are the medical adherence, Seeing
that the patient lives a sedentary lifestyle these may affect his therapeutic level The number of drugs administered.
TASK Assessment Criteria
Question 12 Mr. McFarlane’s wife Yu Yan is originally from China. If Mr. McFarlane were to become
unresponsive you would need to communicate with her. In 75 words, explain a strategy you could
use when talking to Mrs. McFarlane that would demonstrate appropriate cultural respect and
understanding during your interaction.
Response: Good communication skills are required when talking to a patiient. Speaking slowly and clearly, use short
and simple sentences and avoiding jagon.Using gestures to demonstrate of what is saiid may be important for well
understanding...
TASK Assessment Criteria
Question 13 Mr. McFarlane, has been reviewed by the Dr. and several other relevant health professionals. Mr.
McFarlane has all discharge planning and referrals complete prior to discharge. The Hospital Dr.
has advised Mr. McFarlane to follow up with his GP in one week. Now, Mr McFarlane needs to be
discharged from care, and the appropriate records need to be kept. Complete the following
discharge summary by indicating which option is correct in the spaces provided.

In each box below, select the correct option.
Discharge planning needs:
click here...
Living arrangements:
Lives with family/carer
Discharge transport
arrangements required:
Yes, wife collecting husband
Does the patient have
any concerns related
to discharge?
No
Does the patient require
any services for showering,
wound dressings,
medication
management etc?
Yes
Does the patient already
have community services?
No
Does the patient require a
medical certificate?
No
Was discharge
information provided
and recorded in
progress notes?
Yes
Should follow up
appointments made and
given to the client?
Yes
Should patient have own
medications, x-rays and
valuables returned?
No
Should invasive devices be
removed?
No
Should a medical
discharge summary be
completed and given
to client?
Yes
TASK Assessment Criteria
Question 14 Below is a table listing a range of common diseases, disorders and their symptoms. Using the list
of body systems below, specify which body system relates to each associated disease or disorder
and its symptoms. Also, for each body system, write a sentence about its function and the
interactions it has.
 Lymphatic system
 Endocrine system
 Musculoskeletal system
 Respiratory system
 Integumentary system
 Urinary system
 Digestive system
 Reproductive system
 Cells, tissues, organs
 Special senses
 Cardiovascular system
 Immune system
 Nervous system
Common Disease Body System Body System Function Body System Interactions
Splenomegaly:
Enlargement of the
Spleen, usually as a result
of infection, disease or
malignancy.
Urinary system. Stores and eliminates fluid
waste.
It balances the body
electrolyte ...
Diabetes mellitus: The
complete absence,
deficiency of or resistance
to the hormone insulin. It
can manifest as
hyperglycemia (high blood
glucose).
Endocrine System... Secrets hormones responsible
for regulating cells functions
in the body
Significance for the body
development. The system is
important for metabolism and
mineral balance.
Common Disease Body System Body System Function Body System Interactions

Osteomyelitis: An
infection usually following
surgery or open fractures,
causing fever, pain and
purulent discharge.
Muscle skeleton It is a connection to other
bones to enhance the support
of the body.
Supports body movement and
homeostasis.
Emphysema: Usually
develops from progressive
destruction of elastic
tissue around the alveoli,
causing an inability to
recoil. Symptoms include
barrel chest and shortness
of breath.
Breathing System or
respiratory system
Regulate the exchange of
oxygen and carbon dioxide in
and outside the body ...
Makes sure the body organs
receive the oxygen they
require for their functioning..
Basal cell carcinoma: The
most likely to occur on
sun-exposed sites, usually
appearing as a shiny
nodule and later breaks
down to become an ulcer
with irregular edges.
Special Senses.. Detect environmental stimuli
and may help to gather the
environment information..
.Responsible for the five
senses.
Renal Calculi: Stones of
oxalate and phosphate
found in the kidney. These
cause infections and
back/abdominal pain.
Urinary System ... Responsible for removing
fluid waste ..
Coordinates with the renal
system to regulate the blood
volume and metabolites...
Jaundice: Develops when
there is an abnormality of
bilirubin processing.
Yellowing of the skin and
mucous membranes is a
sign of abnormal bilirubin
metabolism and excretion.
Lymphatic system.. It helps to remove the body
toxins outside the body.
Coordinates with the white
blood cells to fight the
infections...
Benign prostatic
enlargement: This occurs
when hyperplastic nodules
form around the urethra
and may obstruct the flow
of urine, causing urinary
retention.
Reproductive
system ..
The organs are responsible
for the reproduction and
removal of urine from the
body .
Removes the fluid waste from
other parts of the body.
Responsible for production
Neoplasms/Tumours:
Rapidly growing masses of
tissue that continue to
grow after the initial
stimulus has ceased.
Nervous system .. Process and interplate
intercessory input...
Collects the intercessory input
from the body and
environment...
Labyrinthitis: Caused by
the development of fistula
from a cholesteatoma. It
presents as vertigo,
nausea, and nystagmus.
Reproductive
system ...
Ensure the survival of the
species through production.
Endocrine system and urinary
stem work together with the
reproductive system ...
Common Disease Body System Body System Function Body System Interactions

Myocardial infarction:
Unrelenting, severe,
crushing chest pain that
continues at rest and
often radiates down the
left arm, blockage to a
branch of the coronary
artery. Damage is
permanent.
Cardiovascular
System..
Transports the body
nutrients, oxygen throughout
the body
.Protects the body against the
disease and infections.
Acquired immune
deficiency syndrome
(AIDS): Develops from the
human immunodeficiency
virus (HIV). Symptoms
vary from diarrhea to
lymphoma depending on
progression.
Immune System ... Protects the body against
infections
Fights the dangerous
antibodies that may infect
other organs in the body
Bacterial Meningitis:
Causes inflammation of
the subarachnoid space,
appearing as severe
headaches and
photophobia.
Nervous System .. Responsible for controlling
body communication
Coordinates with the other
body systems such as the
digestive system, respiratory
system for better functioning...
TASK Assessment Criteria
Question 15 Within the body, there are different levels of structural organization and complexity. Complete
the following paragraph about the structural organization of the body by inserting the words from
the bank below into the correct places (the words may be used more than once).
 Skeletal
 Atoms
 Molecules
 Cells
 Cardiac
 Tissues
 Organs
 Smooth
 Systems
The words in green are INCORRECT. Click on each and select the correct word.
Cells combine to form tissues . There are many differing types of cells within the body. Cells are the smallest
independent unit of living matter in the body, these can be specialised. Tissues in the body with similar functions
are found together and form organs . Organs are made up of a number of different tissues that have evolved to
carry out a specific function. There are three types of muscle tissue, which are skeletal muscle tissue, smooth
muscle tissue and cardiac muscle tissue. Together, tissues and organs make up the systems within the body.
And, these systems provide the survival needs of the body.

TASK Assessment Criteria
Question 16 Use the directional terms in the table to fill in the missing word from the sentences.
 Medial
 Lateral
 Distal
 Inferior
 Front view
 Shoulder
 Superior, middle and inferior
 Anteriorly
 Superior
The words in green are INCORRECT. Click on each and select the correct word.
The thyroid gland is situated anteriorly to the parathyroid gland.
The anterior view of the skull would show the front view of the skull. The right lung is divided into which three (3)
distinct lobes. The front view, medial & lateral.
A fracture of the proximal humerus is located near the medial.
The wrist is medial to the elbow.
The auricle is lateral to the cochlear.
Anatomically, the heart is located medial to the humerus bone of the arm.
The head is medial to the thorax.
The spleen is distal to the heart.