Perform Clinical Assessment and Contribute to Planning Nursing Care

This document provides instructions for a role play activity in which students learn how to perform clinical assessments and contribute to planning nursing care. The scenario involves a patient with multiple health issues and cultural considerations. Students will demonstrate their skills in gathering information, using appropriate equipment, interpreting data, and documenting findings. They will also learn how to address the emotional and physical needs of the patient and plan for discharge. The document includes objectives, tasks, and references for further reading.

HLTENN003 Perform clinical
assessment and contribute to planning
nursing care
HLT54115 Diploma of Nursing
ASSESSMENT TASK 2 – ROLE PLAY
Instructions to the Student
Task 2 – Role play  You are required to go through the role play below and
answer all questions
 Wherever applicable, the necessary task is to be
demonstrated during the role play. Responses to remaining
questions can be typed or submitted handwritten
 Written responses must be legible and in pen NOT pencil
 It is important to proofread your answer paper, to avoid
grammar and spelling mistakes
 Please use only APA format of referencing. Do not copy and
paste text from any of the online sources. SCEI has a strict
plagiarism policy and students who are found guilty of
plagiarism, will be penalized
 Write your name, student ID, the assessment task and the
name of the unit of competency on each piece of paper you
attach to this assessment document
 You are required to submit this assessment to your
trainer/assessor by the due date
Due Date The trainer/assessor will inform you of the due date.
You are the Enrolled Nurse working in the day surgery clinic at the Alfred
Hospital. You are assigned to care for Mrs. Kaur who is scheduled for a
colonoscopy under Dr. Prichard.
Mrs. Kaur is 65 years old lady of Indian origin; speaks limited English and
she is the Carer for her husband Mr. Singh who has CVA recently. They
don’t have kids. They don’t have any relatives in Australia. She is
extremely fond of meat and believes that fruits and vegetables have only
water in them and are not nutritious. She is on medication for DM type 2,
HTN and uses hearing aids. She has been admitted with the complaints of
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HLTENN003 Perform clinical assessment and contribute to planning nursing care

abdominal pain, bloody stool, burning micturition and anaemia. She has
done the bowel preparation and has been fasting from mid-night.
She used taxi services to reach the hospital this morning. She does not
have an escort if she gets discharged this afternoon. She looks anxious
and worried. She brought all her previous medical records, blood results
and other medical documents with her. Her husband is already admitted
in the medical ward on the second floor of the hospital. He has been
ringing your floor twice for an update on Mrs. Kaur. He seems worried and
wants to see his wife as soon as the colonoscopy procedure is completed.
As colonoscopy is a day procedure, you are responsible to complete the
admission requirements and plan the discharge for Mrs Kaur.
The doctor’s discharge notes are written in the following order:
 Name
 Age
 Gender
 URN Number
 Address
 Diagnosis
 Findings of colonoscopy
 Treatment recommendations
 Follow up date
 Dietary recommendations
Students are required to demonstrate the following elements on a fellow
student and record the same in the attached progress note:
Objectives Satisfacto
ry
Unsatisfact
ory
1. Introduce yourself and explain the
procedure to Mrs. Kaur.
Hi Mrs. Kaur, I am the enrolled nurse who is in
charge of taking care of you. Please feel free and
comfortable with me. Kindly let me know the
details about the problems that have been faced
by you. I will be managing the entire test which
is really necessary for your diagnosis.
2. Gather information from
patient/family/carer using culturally
appropriate strategies.
I will be engaged in knowing about the medical
history of patient. For this I will be involved in
communicating with her husband. I will make
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HLTENN003 Perform clinical assessment and contribute to planning nursing care

sure that no cultural belief, thought, value of
patient is been hampered by me.
3. Use the provided admission paperwork
to document the patient’s gender, age,
religion, cultural background.
I will be engaged in knowing about
patients age, gender, religion. Proper
paper work will be done by me. It is
really essential to know about the
patients properly so that better nurse
and patient relationship can be
established. All legal laws rules and
regulations will also be followed while
doing paper work.
4. Perform the following clinical nursing
assessments on Mrs. Kaur using the
appropriate equipment:
You will be asked to show the proper
demonstration of usage of the
equipment. Record all readings
accurately.
 Height and weight: Stadiometers.
Used to measure patient height, a
stadiometer is an essential piece of
equipment at any medical practice
 Body Mass Index: The body mass
index (BMI) is a measure that uses
your height and weight to work out
if your weight is healthy.
 Temperature, Pulse and Respiration:
This can measured by using
temperature monitoring device.
 Blood Pressure: sphygmomanometer can
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HLTENN003 Perform clinical assessment and contribute to planning nursing care

be used.
 Blood Glucose level: Gluco meter
 Urine analysis. Urine collection tube
5. Use critical thinking to interpret
objective and subjective data that you
have obtained from the above
mentioned assessments, and
determine if it is normal or abnormal.
She has been admitted with the
complaints of abdominal pain, bloody
stool, burning micturition and anaemia.
The above mentioned test are been
done in order to analyze the problem of
patient.
6. Document the findings of Mrs. Kaur’s
patient history in the Nursing progress
notes provided to you. Make sure you
include the following domains:
 Lifestyle patterns: She is extremely
fond of meat and believes that fruits
and vegetables have only water in
them and are not nutritious
 Health history: She has been given
medication for DM2 and HTN.
 Current health practices: She has
also been a problem related to
hearing. She is not involved in
taking nutritious diet
 Coping mechanisms: She needs to
be provided with support and
assistance to enhance her health
outcome (Rekman et.al., (2016).
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HLTENN003 Perform clinical assessment and contribute to planning nursing care

 Current issues and needs:
abdominal pain, bloody stool,
burning micturition
7. Explain how you will clarify the emotional
and physical needs of the Mrs. Kaur’s
husband.
Mrs. Kaur husband will provided with full
details about the condition of her wife.
Nurses will provide him with emotional
support.
8. What questions will you ask Mrs. Kaur
upon admission. What information can be
used from this to plan her discharge?
During the time of admission Mrs. Kaur
age, religion, culture will be asked.
9. What are the cultural values and/or
attitudes of Mrs. Kaur towards health that
may have an impact timely discharge
from the hospital?
Nurses must analyze that they must not
be engaged in hampering the culture,
attitude and value of patients.
10. What community and support services are
available to Mrs. Kaur that may aid in her
discharge
The Discharge Support Service
coordinates Short Term Support services
which aim to assist patients who are
returning to their homes after a stay in
hospital (Kamphaus, (2019).
11. What personal aids or devices is Mrs. Kaur
currently using for sensory perception of
hearing?
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HLTENN003 Perform clinical assessment and contribute to planning nursing care

Hearing aid been used by mrs Kaur
currently for the problem of listening.
12. How will you ensure that Mrs. Kaur returns
to the GP for a review later?
I will make sure that Mrs Kaur returns to
review later so that her health outcome
improves. I will motivate her to meet GP
so that no problem in future can be faced
by her.
References
Kamphaus, R. W. (2019). Clinical assessment of child and adolescent intelligence. Springer.
Rekman, J., Gofton, W., Dudek, N., Gofton, T., & Hamstra, S. J. (2016). Entrustability scales:
outlining their usefulness for competency-based clinical assessment. Academic Medicine,
91(2), 186-190.
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HLTENN003 Perform clinical assessment and contribute to planning nursing care