Diploma of Nursing Assessment: Clinical Assessment and Skills

This assignment presents a comprehensive nursing assessment, encompassing three key tasks. Task 1 focuses on answering questions related to developmental stages, physical and psychosocial growth, and various health-related topics. Task 2 involves a role play scenario where the student, acting as an Enrolled Nurse, interacts with a patient, performs clinical assessments, and plans for discharge. The scenario includes gathering patient information, performing assessments such as height, weight, vital signs, and blood glucose levels, and documenting findings. Task 3 is a skills assessment where the student is evaluated on their ability to perform nursing procedures, including the development of a nursing care plan for a patient with a fractured tibia, analyzing health history, identifying risks, and outlining care strategies addressing physical and emotional needs, and also the practical demonstration of nursing skills in a simulated lab environment. The assessment covers aspects of patient care, including activities of daily living, and the rationale for nursing interventions.

Student Assessment
HLTENN003 Perform clinical assessment and contribute to planning nursing care
HLT54115 Diploma of Nursing
ASSESSMENT TASK 1 – QUESTIONING
Instructions to the Student
Task 1 – Questioning  You are required to answer all questions in Assessment Task
1 – Questioning
 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.
No. Questions
1. Write a short note on the following developmental stages of the toddler, preschool
and school aged child
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a. Physical Growth
b. Psychosocial growth
c. Cognitive development
d. Motor development
2. Write a short note on the physical growth and development of an infant (0-12
months)
3. What is the importance of PLAY in a child’s development?
4. Mention 4 impacts that a family may have if a child gets hospitalized.
5. Write a short note on the developmental stages of adolescence. Mention 4 common
health issues they face during this period.
6. Write a short note on adulthood. Mention 3 major activities for each phase of
adulthood.
7. What impact does infertility have on parents?
8. Describe 2 theories that enable understanding of human growth and development.
9. Mention 3 influences that the following have on growth and development:
a. Genetics
b. Environment
10. Mention 4 health care needs of a family.
11. Mention 4 gender specific needs for each gender
12. Describe any 2 equipment that are used for undertaking health assessments in the
following domains:
a. What is its Scientific name?
b. What is its significance?
c. Images of the equipment
d. A step by step guide of how to use this equipment.
e. How do you collect and utilize data from this equipment?
13. How can an EN assist a person in activities of daily living?
Give examples of 3 aids that you can use for the same.
14. What is the principle for health assessment?
15. a. Explain with an example of steps involved in determining that a patient is
deteriorating.
b. How will you assess the patient’s level of consciousness?
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Student Assessment
c. How and when should concerns be raised about this patient’s deterioration?
Whom should these be reported to ?
16. What is the rationale for mealtime management in Nursing Practice?
17. Write a short note on wellness approach to health on the following aspects:
a. Physiology
b. Psychosocial aspects
18. Mention any 2 variations in health needs and activities of daily living for a person
with a disability across his/her lifespan.
19. Describe briefly ONE method to assess the level of consciousness of a patient.
20. Define Pupillary reaction. How will you measure constriction/dilation of a pupil ?
21. Mention 4 Neurological reflexes and describe briefly their significance and how to
assess them.
22. Explain what is meant by a Person Centered Approach?
Why is it important for nurses to develop health care assessments?
For your answer you may refer to the resources for the Core Standards for nurses
who support people with a disability (NSW Family and Community Services).
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Student Assessment
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 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.
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
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Student Assessment
2, HTN and uses hearing aids. She has been admitted with the complaints of 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 Satisfactory Unsatisfactory
1. Introduce yourself and explain the procedure to
Mrs. Kaur.
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Student Assessment
2. Gather information from patient/family/carer
using culturally appropriate strategies.
3. Use the provided admission paperwork to
document the patient’s gender, age, religion,
cultural background.
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
 Body Mass Index
 Temperature, Pulse and Respiration
 Blood Pressure
 Blood Glucose level
 Urine analysis.
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.
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
 Health history
 Current health practices
 Coping mechanisms
 Current issues and needs
7. Explain how you will clarify the emotional and
physical needs of the Mrs. Kaur’s husband.
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Student Assessment
8. What questions will you ask Mrs. Kaur upon
admission. What information can be used from this
to plan her discharge?
9. What are the cultural values and/or attitudes of Mrs.
Kaur towards health that may have an impact timely
discharge from the hospital?
10. What community and support services are available
to Mrs. Kaur that may aid in her discharge
11. What personal aids or devices is Mrs. Kaur currently
using for sensory perception of hearing?
12. How will you ensure that Mrs. Kaur returns to the
GP for a review later?
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Student Assessment
ASSESSMENT TASK 3- SKILLS ASSESSMENT
Instructions to the Student
Task 3- skills
assessment
 This assessment must be deemed satisfactory by the trainer/assessor
prior to commencing professional practice
 The assessment is conducted in the SCEI simulated nursing
laboratory
 This assessment task requires the student to be directly observed by
the trainer/assessor in performing the tasks described below in a safe
and competent manner
 The student will be required to achieve successful performance in
demonstrating the listed nursing procedures
Due Date The trainer/assessor will provide a date and time for this assessment
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Student Assessment
Luke Parker, a 23-year-old male sustained an
injury during his AFL tryouts. He was
diagnosed with a comminuted fracture of the
shaft of his Right tibia. He underwent an Open
Reduction and Internal Fixation (ORIF) with
Interlocking Intramedullary nailing and bone
grafting.
The rehabilitation protocol involves strict
immobilization for 6 weeks after surgery. The
doctor has also advised him to quit smoking.
Below is a picture of his post-operative X-ray.
Always an avid footie fan, he is depressed that
he has to lay in bed for a long time and cannot
play anymore. He and his family are orthodox
Christians. His father explains to him that God
has better plans for him.
Now take the look at the timeline of events that
occurred that day.
10:00 am- Pt shifted to OR room
12:00 noon – Pt shifted to recovery
12:30 pm – Pt shifted to post op ward where
you work.
Vitals at the time of clinical hand over:
BP: 110/70 mm of Hg
Temperature: 36.7`C
Pulse: 90/min
Respiratory rate: 16/min
Oxygen sat: 97% of SpO2 on RA
Drain: 30 ml, dark red
GCS: 14/15
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Student Assessment
The PACU nurse mentions that the following
drugs have been administered before shifting:
Inj Amoxyxillin 500mg IV at 12:25 pm
Inj. Metaclopromide 10mg IV stat at 12:25pm
Inj. Morphine 2mg IV stat 12:20 pm
Vitals at 12:45
BP: 100/70 mm of Hg
Temperature: 36.7`C
Pulse: 112/min
Respiratory rate: 10/min
Oxygen sat: 89% of SpO2 on RA
Drain: 30 ml, dark red
GCS: 12/15
Instructions:
 Read the scenario carefully.
 You are required to answer PART A questions 1-8. This involves developing a Nursing
Care Plan. Please use the attached template for your final draft.
 For PART B, you will be assessed in the simulated lab environment.
Part A
Questions
1. Analyse Luke Parker’s health history and the above clinical assessment findings, and
identify risks and likely impacts the surgery has on his ADLs. What healthcare is
required here?
Analysing the case scenario of Luke, it becomes important to note that the blood
pressure is on rise. The increase in blood pressure can is one of the leading cause of
increasing the level of calcium in urine. The excessive elimination of calcium through
urine can often lead to osteoporosis in the longer run or weak bone density that can
lead to delayed healing of the broken bones. (mayoclinic.org, 2019)
In similar regards, the increase in the pulse rate acts as a precursor to increase the
blood pressure. Increase in blood pressure can lead to chances of myocardial
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Student Assessment
infraction leading to possible problems
2. Ouline a Nursing Care Plan using a problem solving approach. Ensure stratgeic care
planning approporiate to Luke’s needs.
Make sure you include his
-Physical: The physical need of Luke is to ensure that he is out of pain. It is for the
same reason he is administered with Amoxcillin, a pain relieving drug. Following are
the ways to care for pain:
Assessment: Use of Amoxcillin to relieve pain
Nursing diagnosis: Acute pain related to the process of fracture healing and operation
Planning: After 20 minutes of nursing intervention, Luke would be able to
demonstrate the implementation of relaxation techniques
Intervention: It is important to perform assessment of pain experienced by Luke. In
addition to that, Luke should be subjected to a quiet environment where he can reast.
As the Luke is subjected to restricted to limited mobility, it is important to help him
provide him a comfortable resting position.
Rationale: To wear clothes that are comfortable and not too tight that can further work
on promoting relaxation
-Emotional:
Assessment: Visbly upset when subjected to series of bed rest tenure for 6 months
Nursing diagnosis: Low morale that states there is a risk for prone behaviour in
regards to the lack of knowledge about the fracture. High level of blood pressure
indicates hypertension in the arteries. However, emotional stress largely does not
correlate to high blood pressure. Nevertheless, temporary increase in pressure can
often lead to low emotional mood
Planning: After hours of intevention through nursing process, Luke would exhibit
understanding about his process of healing.
Intervention: Luke needs to be subjected to quite environment to speed up the event
of sleep. Luke needs to take rest and thus reduce the emotional trauma
Rationale: A clear understanding about the emotional needs can help Luke to respond
better to the medication and treatment
-Spiritual And/Or Religious
Assessment: Family saying God has better plans for him, complicated grieving
Planning: After analysing his religious prospect his treatment care plan can be formed
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Student Assessment
Intervention: Assess the emotional need of the patient in alignment to the religious
demands. A holistic care plan is provided keeping in mind the religious constraints
Rationale: Religious understanding can make the family feel good about treatment
-Psychosocial Needs.
Assessment: Reported grieving
Nursing diagnosis: Highly upset about 6 month bed rest
Planning: Show empathy and explore the feelings of anger and frustration
Intervention: Excessive prolonged emotional response
Rationale: Knowledge of accepting the scenario can reduce emotional stress
You will need to consider stress management strategies as he feels worthless and never be
able to play footie again.
3. How will you recognise the signs of a detoriorating patient and determine the levels
of his conciousness.
Following are the ways using which signs and symptoms of deteriorating patient can
be recognised:
Change in pulse quality (irregular, absent, weak or even bouding pulse)
Delay in the capillary refil
Abnormal swelling
Abrupt change in body temperature
Pain at unusual places
Determine the levels of his conciousness can be done through the following conditions:
Pupillary assessment
Presence of pulse
Presence of respiration
Responding to verbal commands such as open your eyes
4. How, when and to whom should you raise concerns of Luke’s detorioration?
The fall in respiratory rate and even the level of oxygen saturation in blood can be
termed as a matter of concern (Loi et al. 2016). In similar regards, it becomes
important to note the fact fall in the pulse rate can be treated as a case of medical
emergency. The allocated nurse needs to be informed first, and the doctor taking care
of Luke needs to be contacted
5. What intervention should be taken to manage the deterioration?
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