Performing Nursing Interventions for a Person with Complex Needs

CRS170
Revision 101
July 2017
Page 1 of 22
Assessment Task 4/5: Workbook Assessment
Student Version: Knowledge
Student information
Student name: . Student ID: .
Section A – Program/Course details
Qualification code: HLT54115 Qualification title: Diploma of Nursing
Unit code: HLTENN005 Unit title: Contribute to nursing care for
a person with complex needs
Section B – Assessment task details
Assessment number: 4/5 Semester/Year: Semester 1 2019
Due date: To be provided by your
Assessor.
Duration of assessment: 2 tutorials
Assessment task
results:
This assessment task will be marked as:
☒ Ungraded result: Satisfactory or Not Satisfactory
☐ Other (eg points): Graded once deemed satisfactory
Section C – Instructions to students
Task instructions:
 Worksheet will be completed over two tutorials.
 Students will need to access resources on Brightspace such as readings and PowerPoints to work on
worksheet outside of tutorials.
 Students MUST answer all questions fully (explanations relating specifically to the scenario is required).
 Answers for the worksheet will be covered in the tutorials.
 Completed worksheets will be returned to the session teacher.
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CRS170
Revision 101
July 2017
Page 2 of 22
Section D – Conditions for assessment
Conditions:
Student to complete and attach Assessment Submission Cover Sheet to the completed Assessment Task.
Equipment/resources students must supply: Equipment/resources to be provided by the RTO:
 Recommended text:
Koutoukidis, G, Stainton, K, & Hughson, J. (2017).
Tabbner’s Nursing Care Theory and Practice (7th ed,).
Sydney, Australia: Elsevier.
Tiziani A, 2013 Havard’s Nursing Guide to Drugs (10th
ed.). Mosby Elsevier
 Pens
 Assessment paper
 Resources on Brightspace and face to face
discussion facilitated by a teacher.
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CRS170
Revision 101
July 2017
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Student Instructions
Read the following Scenario and answer the questions using the information provided below.
Scenario:
Jessica Fong is an active thirty (30) year old who was involved in a motor vehicle accident. She has
sustained a closed head injury, and a fractured right tibia and fibula, which required an ORIF (open
reduction and internal fixation). Her other injury is a perforated bowel. She has had a laparotomy
and loop ileostomy formation. Jessica has a NG tube (Nasogastric tube) inserted prior to surgery, it
remains insitu for nasogastric feeds to meet her nutritional needs.
Medical history: No significant medical history. Allergy to strawberries causes abdominal pain and
diarrhoea.
You undertake a systems assessment of Jessica at the commencement of your care. These are your
assessment findings:
CNS: Alert, orientated, obeys commands. Slightly drowsy as she is post anaesthesia. Pupils size 3 and
reactive to light bilaterally. Full function and movement to both arms and left leg, right leg injured. No
complaints of pain due to analgesia given intra operatively.
CVS: Temp. 36.7C, HR 88 bpm regular. Colour, god well perfused. Peripheries warm. IV(Intravenous)
cannula site intact.
Resp: Air entry L(left)=R (right). RR 18rpm. SaO2 = 97% on room air
Renal: Has not passed urine since return to ward one (1) hour ago. Pre-operative urinalysis NAD (No
abnormalities detected), SG (Specific Gravity) 1.010, Ph (acid-alkali balance) 5.5
GIT: Ileostomy bag 75mls rose coloured fluid. Stoma red. Abdomen soft, no distention.
Endocrine: BGL (Blood glucose level) = 6.5 mmols
Musculoskeletal: Neurovascular assessment – left leg full range of movement and sensation. Right leg,
Jessica is able to wriggle her toes, no other movement due to operation site. Has full sensation on right leg.
Both legs pedal and tibial pulses strong. Capillary refill under 2 seconds both feet. Legs warm and well
perfused.
Skin: No redness or loss of skin integrity
Social: Divorced, has sole custody for her seven (7) year old daughter. Has no contact with ex-husband
and receives no financial help for their daughter. She works full time in a pharmacy and has limited child
care assistance from her parents who also both work. She is very anxious about the impact of her injuries
on her ability to return to work and care for her daughter.
Post-operative orders:
 RPAO (routine post anaesthetic observations)
 Neurologic and neurovascular observations 4/24 prn
 Nurse with head elevated to 40%
 RIB (rest in bed) until surgical and physiotherapy review in 24 (twenty-four) hrs. Mobilise with a
walking frame after review.
 Abdominal wound dressing remains intact until surgical review.
 Ileostomy and stoma care prn (as necessary) as per protocol
 NGT (Nasogastric tube) gravity feeds 50mL/hour of Osmolite
 NBM (Nil by mouth) until bowel sounds return.
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CRS170
Revision 101
July 2017
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Element 1: Perform nursing interventions to assist a person with complex needs
1.11.2 Perform nursing interventions based on the person’s predetermined plan of care
Question
1.1a
Jessica sustained a closed head injury and is to be nursed
with her head elevated by 40 (forty) degrees. Explain why
this is important.
Satisfactory response
Yes ☐ No ☐
Answer:
Head injury leads to alteration of pressure in the cranium, cerebral perfusion pressure
and the blood flow to the cerebrum. Closed head injury increases the intracranial
pressure and elevation of the head at 40 degrees therefore decreases the intracranial
pressure building up and the cerebral perfusion pressure as well.
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Teacher Comment:
Question
1.1b
If Jessica’s neurological observations deteriorate for
example her conscious level decreasing, pupil’s unequal
and reacting sluggishly. What complication could this
indicate?
Satisfactory response
Yes ☐ No ☐
Answer:
.....................................................................................................................
......An increase in Intracranial Pressure.
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Teacher Comment:
Question
1.1c
Why is it of neurological importance to manage Jessica’s
anxiety, pain and continence needs? Satisfactory response
Yes ☐ No ☐
Answer:
......To manage Jessica’s stress. Anxiety can lead to urinary incontinence hence
management of continence needs is required for a neurological impaired disorder.
Management of pain is done to make Jessica comfortable.
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Teacher Comment:
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CRS170
Revision 101
July 2017
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1.3 Undertake nursing interventions demonstrating respect for the person’s dignity and cultural
diversity.
Question 1.2 Jessica is at bedrest for 24hrs and is reliant on you for her
personal hygiene, continence and pressure care needs. She
is a young independent person, explain three (3) strategies
you would employ to maintain her dignity and respect her
individuality.
Satisfactory response
Yes ☐ No ☐
Answer:
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...Ensuring that she remains covered while providing her care needs. By doing so it
protects her physical privacy.
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Protecting Jessica’s personal information by avoiding sharing personal information about
Jessica beyond what is necessary for the members of the care team.
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Assisting Jessica with personal grooming , this will make her retain pride in her
appearance.
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Teacher Comment:
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Revision 101
July 2017
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1.3 Encourage the person to assist by undertaking aspects of their own care during care
interventions
Jessica may be going home with her ileostomy bag before she has her reversal surgery. You are going to
assess her ileostomy and at the same time educate Jessica regarding self-management.
Question
1.3a
Discuss assessments you would make regarding the following,
include Jessica’s involvement in your answer. Satisfactory response
Yes ☐ No ☐
Answer:
 Peri-stomal skin:
 ..................................................................................................................I
will remove Jessica’s pouching system
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Assess Jessica in both her sitting and lying positions.
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 Stoma:
 ...I will assess for the state and colour of the stoma by feeling surrounding stoma site
gently for tenderness.
 I will then ask Jessica to cough and feel the cough impulse to assess for parastomal
hernia.
Teacher Comment:
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