Assessment 1, Part B: Case Study

Assessment 1, Part B: - CASE STUDY BRIEF
Student Name
Date
Course HLT54115 Diploma of Nursing
Subject Code and Title NCP106 Nursing care plans
Unit(s) of Competency HLTENN004 Implement, monitor and evaluate nursing care plans
Performance criteria,
Knowledge evidence and
Performance assessed
PC:
1.1, 1.2, 2.7, 3.1, 3.3, 4.1, 4.2, 4.3, 4.4
PE:
1, 3, 4
KE:
5, 6, 7
Title of Assessment Task Assessment 1, Part B: Case Study
Type of Assessment Task Short Response
Length As indicated for each question
Submission
Task Instructions
To complete Assessment 1, Part B, provide your responses to the questions on the Assessment Response
Template below. Your responses must be typed into the spaces provided beneath each question, and the
whole document and associated charts must be submitted to Blackboard as your response to Part B.
Assessment 1, Part B, should build on your responses to Assessment 1, Part A, by demonstrating your
knowledge of the client’s related medical history, Nursing Care Plan recommendations and current vital
signs.
You should discuss rationales and analysis of nursing interventions implemented and complete all
documentation on required charts which will be provided via Blackboard.
These questions must be answered in full. When responding to the questions, you need to pay attention to
the entire question being asked, as well as the prescribed word count. You are required to use the correct
medical terminology when answering all questions and also refer to the assessment charts used.
You will be assessed on your responses and will be deemed as either satisfactory or not satisfactory. ALL
your responses must be marked as satisfactory in order to pass the assessment. If your assessment is not
deemed satisfactory, you will be re-assessed.
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Question 1 (500 word count)
On Sunday at 13:42hrs, you are about to leave to have your lunch break when Mr McFarlane’s wife calls you
from the corridor and states “Nurse! My husband does not look well and something is wrong with him. Please
can you come and have a look at him?” On entry to Mr McFarlane’s room, you notice the following:
 His breathing is short and shallow Pale and clammy skin with cyanosis around his lips and peripheral extremities His eyes are closed and not opening when you call his name; they open when you apply pressure to his
chest He is confused and not making sense His best motor response is localising
 He is lying in a supine position at a 60% angle Vital signs RR: 9, SpO2: 74% Room Air, BP: 100/60, HR: 45, Temp: 38.7 BGL 1.9 mmol/L GCS 12
Discuss your nursing actions and rationales for your decisions, taking into account policies and procedures and
scope of practice as an Enrolled Nurse (EN).
Discuss to whom you would refer the changes in Mr McFarlane’s condition.
Consider, in your response, any concerns about Mr McFarlane’s current vital signs or clinical status; for
example: GCS 12, BGL 1.9 mmol/L, and any relevant previous medical history.
Consider the position of Mr McFarlane and how/if you could safely reposition him, considering his BMI and
safety precautions / risk minimisation actions.
Ensure that the vital signs observations, BGL and GCS are documented on the charts utilised in Assessment 1A
and upload these updated charts as part of your assessment response.
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Response Question 1:
nursing actions and rationales for the decisions: It was been analysed from the case study that patient
was pale and had clammy skin. The Respiratory rate was noted at 9. Normal adult rate is between 12 to
25 and below this it is considered as abnormal. It has been analysed that patient is suffering from
peripheral cyanosis. It is usually caused because of low oxygen level. In this the actions required by
nurse includes Position patient with head of bed elevated, in a semi-Fowler’s position in a 45-degree
angle. It will prevent abdominal content from crowding. Nurses also needs to keep a regular check upon
patients’ position. In order to ensure that they do not slump out of bed. It will compress the diaphragm
and limits down the expansion of lungs. They also need to positioned patient with upper thorax and
pelvic supported. This will significantly help in improving the condition of hypoxemia significantly.
Various safety precautions also need to be taken when doing all these tasks with patients. These nursing
actions will assist in enhancing the health outcome of patient.
Refer to patients’ condition: In this case nurse will refer to health care professional or doctor who are
specialist in treating peripheral cyanosis. They can consider best physician in their hospital care setting. It
is really necessary to refer to physician at this moment so that better interventions can provided to
patient at an early stage. This will help in enhancing health outcome of patient (Bono-Neri, (2019).
Vital signs of patient: It has been analysed from the case study that patient has GCS 12, BGL 1.9 mmol/L.
The GCS is basically 12 and it denotes the head injury. In the mild head injury, the GCS level is between
9-12. It means that in past patient has suffered from the mild head injury. In this patient might go
through pain when opening their eyes. In the present case study patient is unable to open their eyes
instead of giving lots of pressure. It has also been analysed that Blood sugar level of patient is at BGL 1.9
mmol/L. This is too low and patient might be suffering from Hypoglycaemia. Various symptoms that can
be seen in this includes anxiety, palpations, unconsciousness.
position of Mr McFarlane: From the case study it has been analysed that the patient is lying in a supine
position at a 60% angle. Nurses needs to carefully repositioned him. Nurses needs to positioned patient
at semi-Fowler’s position, 45-degree angle when supine and as tolerated. They also need to consider
patients BMI so that better help can be get in repositioning patient. Nurses also needs to be involved in
turning patient in every two hours. If the oxygen level falls below 10% then they need to re-turn patient
at better supine position. Various safety precautions also needs to be taken like if a patient is allowed to
eat they need to provide oxygen in a different manner Schober, (2016).
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