Nursing Care Plans - Assessment 1, Part B: Case Study Response Template

Assessment 1, Part B: - CASE STUDY RESPONSE
TEMPLATE
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:
2.7, 2.8,3.1,3.2, 3.3, 4.1, 4.2, 4.3, 4.4
PE:
1, 3, 4
KE:
4,5, 8
Title of Assessment Task Assessment 1, Part B: Case Study
Type of Assessment Task Short Response
Length As indicated for each question
Submission Due by the end of Module 5.1 (Week 9)
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 as per the THINK Education
Assessment Policy for Vocational Education and Training (VET) before being awarded a Non
Satisfactory mark for the assessment and the unit.
Question 1 (100 -150 words)
December 2020. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Page 1

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:
• He is lying in a supine position
• His breathing is short and shallow
• Pale and clammy skin with slight cyanosis around his lips and peripheral extremities
• His eyes are closed and not opening when you call his name; eyes open with trapezius
squeeze (painful stimuli), and the best motor response is localising.
Discuss the nursing actions you will take to manage this situation, with rationales for your
decisions, including referrals.
Reference required
Response:
Actions
 Need assessment- There is need
for the nursing assessment which
can help to identify the factor
which creating abnormalities in
response and provide treatment
accordingly.
 Managing care- There is need to
manage care during this situation
for handling the current situation.
 Inform doctor when necessary-
Nursing staff should inform the
concerned doctor for better
check-up of condition for proper
treatment.
 Emergency care- After identifying
the specific reason, there is need
to provide emergency care and
treatment.
 Continue monitoring- observation
and continue monitoring is
needed for effective care.
References
Khalil and Lee, 2018. Medication safety
challenges in primary care: Nurses’
perspective. Journal of clinical nursing,
27(9-10), pp.2072-2082.
Rationale
There is need to proper check-up and basic
assessment which can provide the current health
related information about the patient which
should be highly required for better delivery of
treatment and care.
There is need to provide effective care for
managing current situation of the patient for
improvement in health.
Proper assessment can help to identify the reason
of current situation and provide the way for
better treatment of individual.
Informing doctor can help to assist for better
treatment and identification of worsening of
current condition.
To avoid such type of situation in future there is
need for the observation and monitoring of
patient.
Question 2: (100 words)

You have taken a set of vital signs and get the following findings:
RR: 9/min, SpO2: 74% Room Air, BP: 100/60mmHg, HR: 45/min and irregular, Temp: 38.7OC,
BGL 2.5 mmol/L
a) Document the findings (consider data from Q1 and Q2) on the charts used in Assessment
1 part A (Observation and GCS charts ONLY. These charts MUST be uploaded as a part of
your submission)
b) Analyse the patient's condition based on the information in Q1 and Q2 and discuss your
concerns about the patient (You may use the systematic approach to assessment –
ABCDEFGH approach).
Reference required
Response (to part a)
Glasgow coma scale
Behaviour Response Score
Eye opening response Spontaneously
to pain
to speech
no response
1
3
0
5
Respiration Normal time
during emergency
4
2
Vital sign During emergency
during normal
5
3
Response (to part b)
Airway- There is reduction in the respiratory rate along with reduction in the oxygen saturation
level.
Breathing- Breathing is abnormal due to lowering of oxygen
saturation level.
Circulation- Blood circulation is impacted due to lower blood
pressure.
Disability- Mr. F is not able to response to stimuli which shows
disability at the time of emergency situation.
Exposure- There is no any exposure of skin related infection but
having the problem in walking due to fall.
Further information- family has noticed the emergency situation
which is due to not responding towards the call or talk and not able
to respond.
December 2020. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Page 3

Goals- There is the goal to make the patient fit with their improved
health.
References
Umuhire, O.F. and Cattermole, G.N., A Proposed New Mnemonic (ABCDE-FFFF) for the
Management of Critically Ill Patients in a Low-Resource Setting. Rwanda Medical Journal, 77(4),
pp.5-7.
Question 3: (100 - 200 words)
You will need to do a verbal ISBAR handover for Mr. McFarlane to the Emergency Team when
they arrive. Consider what you need to say & write your plan here in ISBAR format.
Response:
I- INTRODUCTION- I am the nursing staff of Mr. McFarlane to take care of his health. Available
for delivering better care and treatment for patient's improved health along with monitoring
health.
S- Situation- Mr. McFarlane is suffering from injury of fall and not able to stand on their own.
There is also som complications which like slowing of breathing, reduced heart rate, blood
pressure deviation, reduced respiratory rate and reduction in oxygen saturation.
B- Background- Patient is suffering from Type II diabetes, Osteoarthritis, Peripheral vascular
Disease, Chronic Obstructive Airway disease, significant advancement of Osteoarthritis.
A- Assessment- Heart rate, blood pressure, respiratory rate. According to patient's condition
there is problem of breathing and heart related problem which is due to smoking.
R- To follow direction- There is need to following up the directions of head nursing staff and
doctor for better delivery of treatment and person centred care to the patient and their better
improved health.
References
Linwood and et. al., 2017. Application of clinical governance in a role 2E hospital: The 2nd
General Health Battalion experience. Journal of Military and Veterans Health, 25(1), pp.23-29.
Question 4 (100 - 150 words)
The Emergency Team have
stabilized the condition of Mr
McFarlane. However, his condition
remains at risk.
Considering your current concerns
about Mr. McFarlane, revise his care
plan on the template below: