HLT54115 Diploma of Nursing

HLT54115 Diploma of Nursing
HLTENN009 Implement and monitor care for a person with mental
health conditions
Written Assessment Student Copy
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Instructions to students
Welcome to the written assessment. To successfully complete the assessment
requirements, you need to follow the following instructions.
Step 1
Read the study guide and the related resources.
Step 2
Read this assessment to gain an understanding of what you need to do to complete the unit.
Talk to your trainer or supervisor and ask for help if you need to.
Step 3
Complete all questions in this assessment. Please write clearly in pen (not pencil). You
may attach printed answers if you prefer. Do not remove any pages from this assessment.
Step 4
Complete the cover sheet and attach to this assessment. We recommend you make and
keep a copy of your assessments.
Step 5
Submit for assessment.
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This assessment is undertaken in the nursing home under supervision by a
Registered Nurse. You must be found competent in a formative assessment in the
clinical laboratory. You will be required to complete the organisations documentation
and attach a copy to this assessment. Ensure that there is no identifying information
on the documentation.
Assessment Instructions:
Students are required to prepare a case history for a client with a mental health
diagnosis who you have provided care for.
Student Instructions
Examine the questions that you must answer before deciding on your client to
ensure that your choice is appropriate. Your answers must be based on the scope
of practice of an Enrolled Nurse.
Word Limit: 1000 words
Answer the following questions in your essay.
Question 1
Gain permission to use the client for their case study and write an explanation as to why
you need to do this. Discuss your responsibilities as an EN in relation to Professional
Standards and the Mental Health Act.
Question 2
Identify the reason for your client’s admission. Outline the client’s nursing assessment
and health assessment findings and how you will assist the client and the family or carer
in therapeutic interventions. How will you ensure that the client and the family or carer
have an understanding of the care? Undertake a risk assessment for the client using the
nursing homes risk assessment tool.
Question 3
Discuss the holistic care that the client has received (based on a biopsychosocial model
of care). Discuss the interdisciplinary approach that has been implemented and the role
the Enrolled Nurse has had in the interdisciplinary team eg developing in conjunction with
the RN the nursing care plan, attending meetings, making referrals. Identify the primary,
secondary and tertiary levels of health care that the client has accessed.
Question 4
In your own words, discuss the any pathophysiology and clinical manifestations of the
health problem/s your client actually presented with. Use appropriate medical terminology
and reference your answer.
Question 5
In your own word discuss the potential complications that may arise for your client in
relation to the symptoms and health problem on admission. Your answer must examine
the physical, psychological and psychosocial aspects of your client’s care needs.
Question 6
In your own words discuss what care you as the EN can provide to minimise the risk of
occurrence of the complications you identified above.
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Question 7
Identify and describe any medical procedures or diagnostic tests that were performed.
Give a definition of these.
Question 8
Discuss how you contributed to the care planning for this client, and ensured that
spiritual, cultural, individual needs were met.
Question 9
List the nursing interventions your client required. In your answer include effective
communication skills such as negotiation, active listening, non-verbal and verbal
communication
Question 10
Choose two (2) of these nursing interventions to detail further.
A) Justify the use of the intervention.
B) Explain the process that you took to complete this intervention safely and
within legislative and organisational guidelines.
C) How did you support your client during the completion of these
interventions?
Question 11
Discuss your role in relation:
A)To documentation
B)To the use of care plans
C)Rehabilitation/Recovery orientated care
Question 12
Identify and discuss at least two health education topics you would be required to discuss
with this client.
Question 13
Identify and discuss the planning needs of your client.
Referencing and layout
Include a reference list and use in-text referencing as required. Take care not to copy sections
from other sources – paraphrase all information and then note the source as an in-text reference.
This assessment is to be typed and attached to this assessment with the documentation.
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Answer 1: Importance of Nursing
Nursing theories are important as they aim at predicting and explaining the occurrences that
happen in the nursing profession. The theories lay a foundation of nursing practice which
further helps to provide a direction to the nursing profession and achieve new developments
in the future. Theories help us to analyse our knowledge on something and what more
knowledge should be gained. There is no way to measure the care provided by any person
which proves that theories are important to guide the nurses and provide better care to the
patients by way of understanding their needs and communicating with them. Nursing
operates under a professional boundary.
Answer 2: Chronic Diseases
Chronic diseases refer to the diseases pertaining to a very long time. Chronic diseases
affects thre lives of people, their independency and their health for a long period of time.
People having disabilities from long time become dependent and can perform only limited
activity. Chronic diseases occur when the symptoms are visible and may last till the time it is
not treated by professionals. Some of the most common chronic diseases are cancer, stroke,
diabetes, arthritis, obesity and heart attacks. It is important to understand the early
symptoms and perform a diagnosis to manage the chronic diseases and prevent its further
occurrences (Moore, et. al., 2016.).
Answer 3: Pathophysiology
Pathophysiology refers to the study that focuses on understanding the symptoms and
functions of an ailing organs due to underlying physical disturbances and accordingly
provide diagnosis and healthcare. Pathophysiology deals with the understanding the
symptoms of the underlying disease and not directly treating with the disease (McCance and
Huether, 2018). Nurses play an important role in educating the patients suffering from
chronic diseases about the process that is required to cure them. They help in walking the
patient comfortably throughout the process. The process generally includes testing,
diagnosing the disease and accordingly provide treatment to the disease.
Answer 4: Professional standards for Enrolled Nurses
The professional standards provide a proper framework for the assessment of enrolled nurse
practices. Nurses are expected to provide direct or indirect care to their patients and work for
their well-being. Enrolled nurses must work in accordance with the policies, procedures and
the laws related to ethically perform their duties. Nurses must ensure that the patients are
provided with the required care and respecting their condition and confidentiality. They
should be accountable and responsible for their own actions. Nurses should use their skills
and competence to provide with the appropriate care planning. They should collaborate with
the Registered Nurses other members treating the patients and accordingly make the care
plans. The nurses should build an understanding with the patients to know their condition
better. This will help them to prepare and document their health records. They should
provide nursing care adhering the safety and quality standards.
Answer 5: Differences between stable and unstable angina
Angina refers to a discomfort or sudden chest pain occurring in the heart area when the
heart muscle isn’t getting enough oxygen-rich blood. It may sometimes feel like a heart burn
but it indicates the symptom of an underlying heart disease. A stable angina is very common
type of angina where the heart works harder than usual and creates a pattern for a future
heart attack. An unstable angina is not common and may cause a sudden pain. This may
eventually lead to a sudden heart attack. This condition requires immediate medical
attention.
Answer 6: Signs and symptoms of CVA
CVA refers to Cerebrovascular accident, which is commonly known as stroke. It means
sudden stoppage of the blood flow to either side of the body due to blockage or any rupture
in any blood vessel. A CVA is an emergency condition and the early signs and symptoms
should not be neglected. A sudden numb feeling or weakness in one side of the body or
face, arm or leg is an early sign. If a patient is confused about the condition and facing
difficulty in speaking and walking or feeling dizzy or loosing balance may be suffering a
stroke. A sudden headache turning severe for no particular reason is also an early symptom.
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Answer 7: Nursing assessment
Part A
Mr. Alan Andrews is a 78 years old man suffering from a low-back pain. The patient was
brought to the emergency and the nursing assessment would comprise a process of
gathering relevant information of his physical and mental condition. The assessment will
start with understanding the root cause of his low back pain.
Part B
Mr. Andrews required to undergo an immediate MRI Scan and an X-Ray scan of his spine. A
Chiropractor can be suggested to provide him relief from the lower back pain.
Part C
Mr. Andrews is facing difficulty in moving with the pain but this would make his vulnerable to
many other problems related to spine.
Answer 8: Nursing assessment
Part A
The observations would be increase in blood pressure due to anxiety and worsening cough
and dyspnea. Along with that, Mrs. Joan Walker also suffered from Diabetes and chronic
heart disease.
Part B
Mrs. Walker suffers from dyspnea which made her anxious and difficult to breathe and
mobilize. As an enrolled nurse, it was important to provide medications, controlled oxygen
therapy and relaxation techniques.
Part C
The Sixth vital sign is considered as the Dyspnea pain which makes the patient experience
breathlessness.
Part D
The referral was made for a Pulmonologist.
Part E
Incentive Spirometry was used to keep the lungs healthy even after a surgery or from a lung
illness.
Part F
The risk from oxygen therapy can be a bloody nose, morning headaches and skin irritation.
Part G
The short-term symptoms of hyperglycaemia are dehydration, weight loss, and frequent
urination.
Part H
The immediate action was to provide her with actrapid which is an insulin given for diabetes.
Answer 9: Code Blue Emergencies
The Code Blue process starts with the First Respondent who calls for help and starts
compression. The Second Respondent brings in the emergency equipment required. The
third respondent will turn the defibrillator on to gain the pulse. Fourth and fifth respondents
will check the IV fluids and documentation process respectively.
Answer 10: Nursing assessment
Part A
The indwelling catheter is put inside the patient body to drain the urine from bladder into a
bag that is kept outside the body. It is kept after a surgery or for urine inconsistencies.
Part B
The device required is an Indwelling catheter tube or Foley Catheter.
Part C
The tube should be checked so that it doesn’t slip away. The patient should not take proper
bathes. The urine bag should be drained on time.
Part D
The ongoing nursing management checks for blood clots in the urine, pain around the belly
and any swelling and inflammation due to catheter.
Part E
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Nasogastric tube feeds the patient but they require proper care and safety. The
complications should be known and tube position should be properly done.
Part F
The tube should be taped and hygiene is maintained by the nurses.
Part G
Temazepam can make the patient dizzy and feel nauseatic. As the patient has the
nasogastric tube, the dosage will be lessened to reduce the side effects.
Answer 11: Approach to chronic health management
Chronic Health Management can be done by coordinating the care planning for patients. The
use of multidisciplinary team approach can help. It is necessary to ensure the efficiency of
team members at all situations and by providing services beyond working hours for
emergency cases.
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Reference List
McCance, K.L. and Huether, S.E., 2018. Pathophysiology-E-Book: The Biologic Basis for
Disease in Adults and Children. 5th ed. New York: Elsevier Health Sciences.
Moore, G., Durstine, J.L., Painter, P. and American College of Sports Medicine,
2016. ACSM's Exercise Management for Persons With Chronic Diseases and Disabilities,
4E. 7th ed. Ontario: Human Kinetics.
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