HLTENN011 Implement and monitor care for a person with acute health problems Assessment 2022

HLTENN011 Implement and monitor care for a person with
acute health problems
HLT54115 Diploma of Nursing
ASSESSMENT TASK 1 - QUESTIONING
Instructions for
completion
 You are required to answer all questions correctly in Assessment
Task 1 – Questioning. You are to complete this assessment in
your own time with access to resources.
 Responses to the questions can be typed or submitted
handwritten
 Written responses must be legible and in pen NOT pencil
 It is important to proof read 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
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Q1. Explain the etiology and outline at least TWO (2) clinical features for each the
following acute health problems.
a) Acute Kidney Injury occurs because of dehydration, injury or blood loss.
Kidney Malfunction and swelling in feet and ankles.
b) Acute gastrointestinal disorders Caused due to infection and symptoms
are constipation and bloating.
c) Ischemic stroke occurs due to narrow down of arteries and symptoms
are drooping face and weakness of arms
d) Complex regional pain syndrome (CRPS) occurs due to abnormal
central nervous system. Symptoms are high pain and inflammation in
Nerves.
e) Asthma occurs due to increase in eosinophils number and symptoms
are breathing problems and airway inflammation
f) Acute unconscious state: due to issues in rhythm of heart and low
blood sugar. Features: person looks like sleeping, and is alive.
g) Angina Pectoris: Due to ischemia of arteries and characterized by pain
in chest and SOB.
h) Cellulitis occurs due to bacterial infection of skin. Features: Redness
and pain in skin.
i) Dehydration occurs due to not adequate intake of water. Features are
vomiting, and diarroea.
j) Haemorrhagic Shock: Occurs due to Bleeding from wounds and internal
bleeding. Features: Weakness, pale skin and unconsciousness.
k) Concussion: falls, motor vehicle accidents are the causes of this
problem. Features are loss of memory and headache
l) Myocardial infarction: Causes high BP and Diabetes. Features:
Tightness of chest and SOB.
m) Nephrolithiasis: Causes are Sedentary lifestyle, high BP. Features: pain
on urination, vomiting.
n) Bacterial Sepsis: Bacterial infection causes it. Features are rapid pulse
and low temperature of body.
Q2 a. List the eight (8) key principles of surgical nursing.
1. Assessment, implementation and planning and evaluation of care
2. Managing electrolyte balance and fluids
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3. Nutrition
4. Pain
5. Infection control
6. Wounds
7. Anxiety and stress
8. And management of possible body image (Nurse Key, 2017).
b. Explain briefly the following surgical procedures using correct surgical
terminology. (30-40 words each)
a) Elective/emergency surgery: Elective surgery is pre scheduled and does not
require any medical emergency. Emergency Surgery is unplanned and
requires immediate surgery.
b) General, local, epidural and spinal anaesthetic and peripheral nerve block:
General anaesthesia is full loss of consciousness, local anaesthesia includes
sensation loss in only some part of body, epidural anaesthesia is numbing of
nerves delivering blood to lower extremity and spinal anaesthesia is injected
through injection in spinal cord and is a type of local anaesthesia and stays
for 3-5 hours; while peripheral is regional anaesthesia where injection is given
to a block of nerves.
c) Amputation is limb removal due to surgery, illness or trauma
d) Open reduction is a surgery done to fix the breakage of bones.
e) Hip replacement is a surgery to remove the joint that is painful
f) Craniotomy is the surgery done to remove the skull part
g) Tonsillectomy is a surgery to remove the bone flap from the skull for some
time
h) Appendectomy: Surgery to remove the appendix
i) Laparotomy: Surgery to make incision in abdominal cavity
j) Hysterectomy: Surgery to remove the uterus
k) Prostatectomy: Surgery to remove the prostate
l) Cataract extraction: The surgery to remove the eye lens having cataract
m) Internal bleeding due to trauma. Excessive bleeding from internal body
organs like liver or spleen.
Q3 TooTooWadadi is a 16-year-old Maori boy from New Zealand who was rushed to
the Emergency department this morning with testicular torsion. After an
initial blood work he was shifted to the operating room. The surgical
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procedure completed at 12 noon and the patient was shifted to the post
operative ICU.
 What is the significance of holistic nursing care ?
Outline the application of holistic nursing in the treatment of Too TooWadadi
considering his age, gender and specific culture.
Identify the warning sign and check the issue without any delay in pre-assessment.
Differential diagnosis of testicular torsion is done to diagnose the illness. Affected
testis is untwisted to check restoration of blood flow and sutures are placed to
prevent the torsion in future. The possibility of testicular tumors should be checked
for the child as the problem has been found considerably high for male children of
age 0 to 16 years old.
Q4 Mrs. KabitaKandel , a 55 year old female was admitted in the female general
ward. She was diagnosed with bilateral osteoarthritis of the hip and has been
posted for a Total hip replacement. She has a family history of type 2 Diabetes
Mellitus and also coronary artery disease. The anaesthetist reviewed the blood work
and after consultation with the patient, gave the clearance for surgery. The surgery
took place at 9 am the next day and the patient was shifted to the post operative
room at 12 noon. The doctors have ordered to commence patient mobilization at 8
pm today.
Name any two (2) Risk Assessments that are required to be performed to ensure
patient’s stability on feet before mobilization.
Pelvic tilt test and Pelvic rotation test (Voight & Robinson, 2010).
Q5A Briefly outline the purpose, complications and nursing management of the
following procedures:
 I/V Intravenous fluid intake is needed for routine maintenance, fluid
resuscitation, replacement and redistribution. When prescribing for IV fluids
the whole electrolyte intake of patient should be kept in mind (National
Clinical Guideline Centre, 2013).
 Central venous catheter (CVC) is placed into large vein in upper arm or
chest. It remains there until the patient is receiving treatment (American
Cancer Society, 2016).
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Q5B
What is Total Parenteral Nutrition ?
Providing the total nutrients through IV route when the food should not be given
through mouth.
Outline at least three (3) indications of Total Parenteral Nutrition.
Obstruction in bowel and Gastrointestinal Fistula
What is the composition of a Standard TPN solution ? Lipid emulsion and dextrose
Q6 What is the rationale for undertaking the following pre and post anesthetic
observations in a patient who has been admitted for surgery?
Pre anesthetic observations specifies fasting and measures High BP or Heart rate
risks. Post anaesthetic observations specify the stability of patient and ensures
normal healing.
Q7
a. List two (2) functions and two (2) complications associated with Peripherally
inserted central catheter (PICC). Functions: It provides faster supply of fluids
in body. It measures central venous pressure. Complications: Thrombosis and
Infection
b. Outline the Nursing Management of a patient prior and post PICC insertion
procedure.
Total infusion rate should not be greater than 4.0 size of catheter and infusion
rate 750 cc/hr. Dressing of the site should be done every 7 days by VAT teams.
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Q8 Outline any three (3) strategies a Nurse can use for pain management in a
patient after surgery with the exception of using analgesics.
Afferent Neural Blockade, Local Anaesthesia and non steroidal anti-inflammatory
agents.
Q9
A. In terms of a patient who is not regaining consciousness, how would you assess
their level of consciousness ? Using coma scale
B. What signs and symptoms of deterioration you need to monitor? Activity
tolerance and vital signs and rapid heartbeat.
Q10
Draw a neatly labelled diagrammatic flow chart representation of the management
of a case of pediatric Cardio Pulmonary Resuscitation for a 5 year old male in a
hospital where 2 certified CPR givers are available
The child faints with Cardiac Arrest. If does not respond?
Activate the Emergency response system. Call for defibrillator and CPR.
Check the breath and pulse.
(Has Pulse/ No Breath) (No Pulse and No Breath)
Start CPR
Provide Rescue Breaths
Assess Rhythm
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VF/ VT No VF/VT
Defibrillation
Provide CPR for few minutes
VF/VT No VF/VT
(IV/IO)Epinephrine Epinephrine
Amiodarone (IV/IO)
Laidocaine
Q11 Explain the physiology behind the progression of a respiratory arrest into a
cardiac arrest.
The respiratory arrest seizes the breathing. The reduced blood flow may slow down
the functioning of heart leading to cardiac arrest.
Q12
A. Excluding Deep Vein Thrombosis, outline at least four (4) complications
associated with bed rest.
Pulmonary embolism and Pneumonia
B. Describe in brief the complex nursing management of a patient who was
recently diagnosed with DVT.
Awareness of Prophylactic measures and awareness about common risk
factors helps in prevention. Pneumatic compression device is used and
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anticoagulant drugs are given.
Q13 List five (5) clinical manifestations and five (5) complex nursing interventions
of Acute Pancreatitis
Los of internal and external compartments in pancreas, flow of secretary transport
obstructs, higher level sof digestive enzymes in blood, pulmonary edema and
respiratory distress.
Interventions: Assess and monitor vital signs, pain management, administer
medications, monitor enzyme levels and assess and monitor the electrolyte
imbalance.
Q14
a.Listthree (3) indications of tracheostomy suctioning.
Respiratory distress, Vomiting and Visible and Audible signs of tube secretions.
b.Briefly outline the nursing management involved in tracheostomy suctioning.
Early signs of obstruction should be identified and it is recommended to have
continuous pulse oximetry for the patients every time. Patency of the airways
should be maintained.
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Q15. Read the scenario and the nursing diagnosis given below and outline at least
four (4) complex nursing interventions.
Scenario Nursing Diagnosis Complex Nursing interventions
required
Mrs Fernando is an 83-year-
old widow who lives with her
two adult sons. Over the
past 15 years, she has
become increasingly short of
breath while gardening and
walking, two favorite
activities. She also has
developed a chronic cough
that is particularly bad in the
mornings. Ten years ago,
her family physician told her
that she had emphysema.
She is admitted to the
hospital with possible
pneumonia and acute
exacerbation of COPD.
Mr. Harris develops the
following nursing
diagnoses for Mrs.
Fernando:
• Ineffective airway
clearance related to
pneumonia and COPD
• Impaired gas
exchange related to
acute and chronic lung
disease
• Risk for impaired
spontaneous ventilation
related to loss of
hypoxemic respiratory
drive and respiratory
muscle fatigue
• Impaired home
maintenance related to
activity intolerance
Asses cough production and
effectiveness and ascultate the lungs.
Treat the altered oxygen supply and
get adequate oxygen intake into lungs
and eject CO2.
Increasing the oxygen in blood,
support gas exchange and reverse the
impairment in mechanics of lungs.
Relaxation techniques and helping
patient in daily activities.
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Q16 Describe in detail the nursing management of a patient with an intercostal
catheter and an underwater chest drainage tube (UWSD)?
Assessment of chest tube and the system tubing. Clamping need to be avoided, and
any movement should be carefully planned to avoid disconnection during
theactivity.
Q17 Outline the nursing management of a patient on BIPAP and CPAP
Interventions for Patients self management and hospital health education.
Q18. Outline the function of each of the following equipment that is present in an
Acute care environment.
Item Function
Bad and Mask,
Endotracheal tube,
Laryngoscope
Supplies air into the patient mouth.
Pulse oximetry Measures the level of oxygen in blood
Vaccum pump and
suction catheter
Sucks air and makes vacuum in pipe
Electrocardiograph Measures electrical activity of heart
Defibrillator Gives does of electric current to heart
Standard IV fluids
and administration
sets
Delivers the fluids into the intravenous blood supply
Infusion pumps Delivers medicines and nutrients in patient body.
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Large bore IV
catheters
Medication fluids and high volume fluid resuscitation
Supplies for
throacostomy
Help in doing incision and performing surgery
Nasal gastric/oral
gastric tubes
Carries the medicine and food through tube to the
stomach
Hard Cervical collars Limits the movement of neck and supports it.
Thermal control for
patients and
fluids/blood
Maintains the appropriate body temperature.
Q19 Classify burns based on causative factors. Describe the 4 degrees of burns as
a result of fire with clinical features.
First, II, III and IV degree burns. I degree burns epidermis only. II degree extends to
dermis, III degree goes to deep reticular dermal layer and the IV degree extends to
the inside whole skin passing through the muscles and bone as well.
Q20.
 What is Venous thromboembolism (VTE)?
Blood clot in a vein
 Outline the types of VTE.
Deep VTE and Pulmonary VTE
 Mention at least two (2) clinical features for each type of VTE.
Deep VTE: Deep vein clot in leg
Pulmonary VTE in lungs and blocks the supply of blood
Q21.
a. Outline atleast TWO (2) extrinsic and TWO (2) intrinsic causes of fractures.
Extrinsic: Injury and location or extent of displacement.
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Intrinsic: Weakness of bone, Ageing
b. What is a green stick fracture? What age group does it affect?
Fracture of soft young bone that affects infants.
c. Outline three (3) clinical features of green stick fractures.
Fracture occurs on the outside of the bone when it bends, It occurs in infants, pain
and swelling.
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Student
Assessment
Q22. Write the indications of use for the following emergency medications that
are used in acute situations.
DRUG INDICATION
Adrenaline
(1000 microgram in 1 mL
injection equivalent to 1:1000)
1000 microgram = 1 mg
allergies
Atropine
(0.6 mg in 1 mL injection)
Pesticide poisoning
Benztropine
(2 mg in 2 mL injection)
Parkinson’s disease
Benzylpenicillin
(600 mg or 3 g powder, dissolve
in water for injections)
Bacterial infections, like tetanus and
pneumonia etc
Chlorpromazine
(50 mg in 2 mL injection)
Psychotic disorders
Dexamethasone sodium
phosphate
(4 mg in 1 mL injection)
Immune system disorders and arthritiis
Diazepam
(10 mg in 2 mL injection)
Anxiety disorders
Dihydroergotamine
(1 mg in 1 mL injection)
Cluster headache attack
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Student
Assessment
Diphtheria and tetanus booster
vaccine
(0.5 mL pre-filled syringe)
Tetanus
Frusemide
(20 mg in 2 mL injection)
Edema
Glucagon
(injection kit containing 1 mg
glucagon and 1 mL solvent in
syringe)
Hypoglycemia
Glyceryl trinitrate
(400 microgram per dose, 200
doses as sublingual spray)
Angina
Haloperidol
(5 mg in 1 mL injection)
Schizophrenia
Hydrocortisone sodium
succinate
(100 mg or 250 mg with
2 mL solvent for injection)
Anti inflammatory medication
Multiple sclerosis
Severe allergies, arthritis, breathing issues,
certain cancers etc
Lignocaine
(100 mg in 5 mL injection)
Local anaesthesia
Metoclopramide
(10 mg in 2 mL injection)
Heart burn in GERD
Methoxyflurane Rapid short term analgesic in acute trauma
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Student
Assessment
(3 mL plus inhaler)
Morphine sulfate
(15 mg or 30 mg in 1 mL
injection)
Severe pain
Naloxone
(2 mg in 5 mL injection)
Opioid overdose
Procaine penicillin
(1.5 g in 3.4 mL injection)
This should read
(1.5 g in 3.4 mL injection)
Corrected May 2013
Bacterial infections
Prochlorperazine
(12.5 mg in 1 mL injection)
Schizophrenia
Promethazine hydrochloride
(50 mg in 2 mL injection)
NAusea
Vomiting
Salbutamol inhaler
(100 microgram per dose,
200 doses)
SOB and wheezing
Salbutamol nebuliser solution
(2.5 mg or 5 mg in 2.5 mL per
dose, 30 doses)
Chronic bronchospasm that s not improving with
conventional therapy
Terbutaline
(500 microgram in 1 mL
SOB
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Student
Assessment
injection)
Tramadol
(100 mg in 2 mL injection)
PAin
Verapamil
(5 mg in 2 mL injection)
Stroke, Heart attack and kidney issues
Q23.
a. What are the clinical manifestations of Acute Myocardial Infarction?
Blocked coronary artery, shortage of blood supply in cardiac muscles.
b. Outline the complex steps involved in its nursing management.
Antiplatelet drugs, are given to prevent the clots and beta blockers lower
down the bP, while Nitroglycerine is given to widen the blood vessels.
References
American Cancer Society (2016). Central Venous Cathetors. Retrieved from
https://www.cancer.org/treatment/treatments-and-side-effects/central-venous-
catheters.html
National Clinical Guideline Centre (2013). Intravenous Fluid Therapy: Intravenous Fluid
Therapy in Adults in Hospital [Internet]. London: Royal College of Physicians.
(NICE Clinical Guidelines, No. 174.) 5, Principles and protocols for intravenous
fluid therapy. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK333103/
Nurse Key (2017). Introduction of Principle sof Surgical Nursing. Retrieved from
https://nursekey.com/introduction-to-the-principles-of-surgical-nursing/
Voight, M. L., Robinson, K., Gill, L., & Griffin, K. (2010). Postoperative rehabilitation
guidelines for hip arthroscopy in an active population. Sports health, 2(3), 222–
230. doi:10.1177/1941738110366383
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Student
Assessment
HLT54115 Diploma of Nursing
HLTENN011 – Version 3.2 January 2019