Assessment 1 Response Template

ASSESSMENT 1 Response Template
Student Name
Date 4/06/20
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 sedentar y life style.
 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 George is a 53 year old man who has presented into hospital with a higher reading of
BGL than normal 15mmols. Patient has constant headaches, feels uneasy and has
shortness of breath when walking or exercise.
(provide an overview of
the patient’s situation)
NAME: George Mcfarlane
ADDRESS: 62 Koala Ave, Belle Hills 2023 NSW
GP: Dr Wing Lo Chaing
MEDICARE NO. 654794329 6/1
DATE: 4/06/20
AGE ON ADMISSION: 53 years
GENDER: Male
RELIGION: Anglican
ETHNICITY: Australian
ALLERGIES: Penicillin
LIFESTYLE PATTERNS: Current smoker, smokes 15 cigarettes per day, occupation long haul truck driver,
sendentary lifestyle, does not exercise, drinks few beers per night
COPING MECHANISMS: Georget telephones his wife daily whilst being away. Drinks few beers each night
SOCIAL: Watches TV drinks a few beers each night.
Lives with his wife and children.
CURRENT HEALTH
PRACTICES / NEEDS: Takes BGL daily. Sees Dr every 6 months
ADL ASSESSMENT: DIET: Australian food, lots of fried food (pie and chips), few beers each night
URINARY AND BOWEL PATTERNS: Passing a lot of urine and
MOBILISATION: Self mobilisation
HYGIENE: George is able to shower himself
FAMILY CONCERNS AND
NEEDS RE: CLIENT:
Wife is concerned George does not come often, doesn't eat well, doesn't manage is
diabetes very well, doesn't exercise
ADMISSION T37 Temperatue
P: 110bpm Beats per minute
RR: 26 Respiratory rate
BP: 170/90 Blood pressure
SaO2: 97% Oxygen saturation
HEIGHT: 180cm
WEIGHT: 118kgs
BMI: 36.4
OBSERVATIONS:
CURRENT MEDICATIONS: Panadol Osteo PRIV Metaformin

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 ward at 1000.
History: George is a man who is 53 years old and is suffering from type 2 diabetes and osteoarthritis in his Left knee.
He is also a smoker who smokes around 30 cigarettes each day. His weight is 118 kg and takes blood glucose level daily.
He visits to doctor for consultation in every 6 months and he is allergic to penicillin.
Assessment: (Provide some points about what was discovered during the health assessment and discussion.
Some are filled out already.)
 Current smoker
 Observations, as recorded in admission observations above. The body temperature of the patient is normal,
heart rate is high, respiratory rate is high, blood pressure is high, oxygen saturation level is normal, the patient is
overweight as his body mass index is high.
 Diabetic
 Reported to the RN.
 Not managing diet plan
Admission Plan: (Provide some points about the actions you recommend taking from this point. Some are filled out
already.)
 Intervention
 Provide regular analgesia as charted
 Extra Care
 Arrange for the doctor to review Mr McFarlane.
 Futher investigation
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 normal range.
Response: Blood pressure is measured in millimeters and given in two figures, systolic pressure and diastolic pressure. The ideal
blood pressure is between 90/60 millimeter of mercury and 120/80mmHg, low BP is considered as 90/ 60mmHg or lower and
140/ 90mmHg or higher is considered as high blood pressure. The blood pressure of Mr. When the range of systolic BP reaches
between 130 and 139 milligram of mercury or if diastolic BP reaches between 80 and 89 mm Hg then it is considered as
hypertension. The blood pressure of McFarlane reaches to 170/90mmHg, which is not a normal range and considered as the
condition of hypertension.

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: As an enrolled nurse, I should report to registered nurse about the findings as the admission observations are
displaying unusual levels which are risky for the patient as the patient was already suffering from type 2 diabetes and the unusual
level may create further issues to the life of patient.
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: In this situation, my responsibility is to provide direct or indirect nursing care to patient and function under the
supervision of Registered Nurse and conduct holistic assessment of patient. As compered to registered nurse, my roles and
responsibilities are mentioned below:
 Enrolled nurse work under supervision of registered nurse. On the other hand, registered nurse works under doctor.
 Enrolled nurse perform holistic assessment involving physical examination, observation and measurements like taking
temperature, blood pressure, pulse, blood sugar levels, respiration etc. of client. On the other hand, the registered
nurse undertakes comprehensive patient assessment.
 Enrolled nurse help with general first aid whereas registered nurse works as a patient’s advocate.