Nursing Admission Assessment and Care Planning
Added on 2021-04-17
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Diploma of NursingNursing Assessment1Australia Institute of Business and TechnologyVersion 1.2- June 2016© Succeed Pty Ltd
Question 1Nursing assessment is the first stage of the nursing process. State four reasons why a nursing history is performed on admission?Nursing history is performed at the time of admission in-order to understand thepatient’s past medical illnesses which serves as a guide for the patient care. It helpsto understand about their cultural values and beliefs so as to plan care based on it. Ithelps us to understand about the present signs and symptoms so as to plan carebased on the patient’s needs. It helps the nurses to provide more appropriate caredirectly based on their features. Moreover, it helps nurses to develop therapeuticcommunication with patients as well as relatives, which helps to render a completeholistic care to the patient (Douglas, 2012). By understanding the physiological,psychological, spiritual, cultural and social aspects of patient, nursing assessmentcan be framed accurately allowing the nurses to plan appropriate patient- centeredcare. Question 2Part AExplain why it is important to involve your client and/or their family whilst conducting nursing assessments?Nursing assessments should be conducted directly in patient by observing him/herso as to identify patient needs and problems. Collecting the history directly will givean accurate and more appropriate subjective data. Involving family in nursingassessment will help them to understand the patient’s problem as well as to gaincooperation from them throughout the nursing care. This will help the nurses to planapt nursing care to both the patients (problems) as well as for family coping. Part BWhat is meant by holistic care?Holistic care is the total or complete care rendered to the patient. This involvesaddressing not only the physiological and psychological needs of client but also theirsociological, spiritual, developmental as well as cultural needs (Douglas, 2012).Question 3List 4 points relating to the documentation guidelines that you must comply with when recording any information.The documents should be clear, legible, concise, accurate and appropriate. Dateand time should be written on every document in order to avoid bias. The involvednurses should document for her/ him not by others. Overwriting or erasing shouldnever be done. Only the facts should be entered. Question 4You are asked to take vital signs on a client. State 4 indications to complete vital signs2Australia Institute of Business and TechnologyVersion 1.2- June 2016© Succeed Pty Ltd
1). Vital signs should be assessed at the time of admission of the clients in a hospitalor health care facility. 2). Assessed as routine process in a health care organizationaccording to the doctor’s order or institutional policy. 3). Before and after a surgery ordiagnostic (invasive) procedures. 4). Before, during as well as after administeringmedications to patients that could affect cardio-vascular, temperature- controlmeasures or respiratory functions. Question 5Match the appropriate term with the correct temperature rangeHyperthermic37.5 – 39.0 0CAfebrile36.2 -37.5 0CHypothermic35.0- 36.0 0CQuestion 6It is recommended to take a confused person’s temperature via the oral routeAnswer: False Because the confused patient may bite down the thermometer. Question 7Tachycardia is an abnormal pulse rate greater than 100 beats/minuteQuestion 8List 4 factors that affect body temperature1). Age 2). Increased exercise or physical activity3). Hormonal changes4). Stress levelQuestion 9When taking a client’s pulse, what 3 characteristics must be assessed?The rate, rhythm, strength and equality of the pulse should be assessed. Question 10List the 4 most common sites for taking a pulse measurement.1).Radial- assessed on the thumb side of forearm or wrist 2). Apical- assessed on 4th to 5th inter-costal space at mid- clavicular line (left). 3). Ulnar- forearm’s or wrist’s ulnar side 4). Carotid- palpated along the sterno-cleidomastoid muscles’ medial edge in neck (Douglas, 2012). Question 11The term for a pulse rate below 60 beats per minute is a Bradycardia3Australia Institute of Business and TechnologyVersion 1.2- June 2016© Succeed Pty Ltd
Question 12When taking a client’s respirations, what 3 characteristics must be assessed?Respiratory rate- by observing the number of full respirations (inspiration and expiration) in a minute Respiratory rhythm- involves determination of breathing pattern by observing the chest/ abdomen Ventilatory depth- is determined by observing the degree of chest wall movement or excursion (Douglas, 2012).Question 13A normal respiratory rate for a child is 20- 30 breaths per minute.Question 14List four factors which may affect pulse oximetryThe light from external sources may interfere with the ability of pulse oximetry in processing reflected light (Lewis, 2013)Patient movement may interfere with light processing.Intravascular dyes can absorb light similar to deoxyhemoglobulin and can lower oxygen saturation artificially.Carbon monoxide (from smoke inhalation) can elevate SPO2 artifically by absorbing light as like oxygen. Question 15List the normal range of pulse oximetry in a healthy adult.Normal range is from 95 to 100 percent in adults. Question 16Define systolic blood pressure (SBP)It is the maximum pressure that is exerted by the blood on the vessel walls at thetime of ventricular systole (when the left-sided ventricle forces blood into aorta). Thenormal range of SBP in healthy adults is 90- 140 mmHg (Douglas, 2012).Question 17Define diastolic blood pressure (DBP)It is the minimum pressure exerted by the remaining arterial blood at the time ofventricles relaxation, just before the commencement of left-sided ventricularcontraction. The normal range of DBP in healthy adults is <90 mm/Hg (Douglas,2012).Question 18An elderly client has a blood pressure of 184/102. The elderly client has stage- 3 Hypertension as his/her systolic BP is above 180mmHg and diastolic BP is above 100 mmHg. It shows that the client is at anincreased risk fro developing myocardial infarction and stroke and hence the nurseshould notify this client’s blood pressure to senior staffs and physician for furthermanagement. Question 19A client has a urinary tract infection. The client will have an increased level of White Blood cells present in his urine.4Australia Institute of Business and TechnologyVersion 1.2- June 2016© Succeed Pty Ltd
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