HLTENN003/004: CVA Patient Case Study & Nursing Care Plan at TAFE

Verified

Added on 2023/06/07

AI Summary

This assignment presents a case study of Mr. Saheed Bott, a 69-year-old CVA patient with right-sided hemiplegia, dysphagia, and dysphasia. The solution identifies factors to consider during assessment, including age, medical history, and conscious state. It outlines physical and psychological factors for the care plan, such as addressing his age, potential social isolation due to the loss of his wife, and his existing colostomy. The response also details neurological assessments, cultural considerations for care planning, and steps for colostomy bag changes. Furthermore, it discusses risks associated with immobility and the use of the Falls Risk Assessment Tool (FRAT) before moving the patient. This document is available on Desklib, where students can find a variety of solved assignments and study resources.

Contribute Materials

Your contribution can guide someone’s learning journey. Share your documents today.

Assessment Task – Written
Student Name Student Number
Unit Code and Name HLTENN003 Perform clinical assessment and contribute to planning nursing care
HLTENN004 Implement, monitor and evaluate nursing care plans
Assessment Type Written
Assessment No. AT2 Assessment Date
Assessment Name Workplace simulated scenario – Case studies
Assessor Name Date Submitted
Student Declaration: I declare that this assessment is my own work. Any ideas and comments made by other
people have been acknowledged as references. I understand that if this statement is found to be false, it will be
regarded as misconduct and will be subject to disciplinary action as outlined in the TAFE Queensland Student
Rules. I understand that by emailing or submitting this assessment electronically, I agree to this Declaration in lieu
of a written signature.
Student Signature Date
PRIVACY DISCLAIMER: TAFE Queensland is collecting your personal information in accordance with NVR (Standard SNR 15.5) for assessment purposes. The
information will only be accessed by authorised employees of TAFE Queensland. Some of this information may be given to the National VET Regulator (ASQA) and/or
Department of Education, Training and Employment for audit and/or reporting purposes. Your information will not be given to any other person or agency unless you
have given us written permission or we are required by law.
Instructions to Student General Instructions:
Read the workplace simulated scenarios on the following pages and answer the
questions related to the information provided in each case study scenario. Please
review the marking criteria for this assessment to ensure you are providing the required
information in your answers.
All parts of each question are to be answered.
Information / Materials provided:
This is an open book assessment.
Assessment Criteria:
To achieve a satisfactory result, your assessor will be looking for your ability to
demonstrate the following key skills/tasks/knowledge as outlined in the marking criteria
for this assessment task.
Number of Attempts:
You will receive up to two (2) attempts at this assessment task.
Should your 1st attempt be unsatisfactory (U), your teacher will provide feedback and
discuss the relevant sections / questions with you and will arrange a due date for the
submission of your 2nd attempt.
If your 2nd submission is unsatisfactory (U), or you fail to submit a 2nd attempt, you will
receive an overall unsatisfactory result for this assessment task.
You must complete this assessment task by the due date provided or you may receive
an unsatisfactory (U) result.
© TAFE Queensland 2024 Ver. 1.1 (21/12/2015) 11890144429009757860.docx
1 of 29

Secure Best Marks with AI Grader

Need help grading? Try our AI Grader for instant feedback on your assignments.

Uncontrolled Copy If Printed
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
2 of 29

Uncontrolled Copy If Printed
If you are unable to meet a scheduled assessment due date, you must notify your
teacher at least 48 hours prior to the due date to request an extension. All requests for
extensions must be in writing on a request for extension form. Extensions are granted in
exceptional circumstances only and must be supported by appropriate documentary
evidence.
For more information, refer to the Student Rules.
Submission details Insert your details on page 1 and sign the Student Declaration. Include this template with
your submission.
Your due date for this assessment can be found in the unit study guide.
Method of submission
Assessment to be submitted via
 TAFE Queensland Learning Management System: Connect url:
https://connect.tafeqld.edu.au/d2l/login
 Username; 10 digit student number
 For Password: Reset password go to
https://passwordreset.tafeqld.edu.au/default.aspx
Instructions for the
Assessor
The student must demonstrate key skills and knowledge identified in the marking criteria
for this assessment task.
Note to Student The student must demonstrate key skills and knowledge identified in the marking criteria
for this assessment task.
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
3 of 29

Uncontrolled Copy If Printed
CASE STUDY 1
Mr SaheedBott is a 69 year old semi-retired university professor. His wife passed away 12 months ago and
Saheed has kept himself busy marking papers from the university, reading and travelling. He has a son who
has recently moved interstate for work. Mr Bott is a Muslim and English is his second language.
Mr Bott wears glasses for reading and other than a permanent colostomy (resulting from a large bowel
infarction in 2005) he has nil significant medical history to report.
Last night Mr Bott was at dinner with friends when he suddenly became unwell and had difficulties
speaking. Mr Bott was brought in by ambulance to the emergency department and was diagnosed as
having had a cerebrovascular accident (CVA) with residual right (R) sided hemiplegia, dysphagia and
dysphasia.
Mr Bott is transferred to the acute medical ward where you work.
Mr Bott appears drowsy but is responsive. He is currently Nil by Mouth (NBM) whilst awaiting a speech
therapist review.
His vital signs on arrival are: T 36.5 degrees C; P 120; R 24; SpO2 94% and BP 180/90.
1a) Identify the factors that you would need to consider prior to and during an assessment? (min 50
words)
.........................................................................................................................................................................
The risk factors need to be identified prior to the assessment like age of the patient and the past medical
history. In cases of CVA during the assessment the conscious rate needs to be identified as in the status of
the patient. Other factors like presence of hypertension, diabetes, smoking or past history of CVA or cardiac
disorders needs to be assessed. .....................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
1b) Using the information from the case study, identify and define three (3) physical or psychologically
factors that will need to be implemented into Mr Bott’s care plan.
.........................................................................................................................................................................
The physical or psychological factors that are required to be implemented in the care plan of the patient will
include old age for which he needs appropriate care. His wife had passed away 12 months before therefore
there might be social isolation and depression which must be considered in the care plan. Finally his past
medical history of colostomy should also be considered as this might have an impact on his present
condition. .........................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
4 of 29

Secure Best Marks with AI Grader

Need help grading? Try our AI Grader for instant feedback on your assignments.

Uncontrolled Copy If Printed
1c) Identify which of the following vital signs provided above are outside normal range and provide the
correct range for each.
Temperature
Temperature is little below normal as the normal is 37c for a given adult...............................................
................................................................................................................................................................
Pulse
The pulse rate is higher than normal as for adults it is 60 to 100 normal................................................
................................................................................................................................................................
Respirations
This is also normal as normal range lies between 12 to 25 breaths per minute......................................
................................................................................................................................................................
Blood Pressure
The blood pressure is high as it normally should be 120/80....................................................................
................................................................................................................................................................
Oxygen saturation
................................................................................................................................................................
This is normal as the normal range lies at 94%.......................................................................................
2. The registered nurse asks you to perform neurological observations on Mr Bott. Identify what data you
would collect and how you would perform a neurological assessment. (min 100 words)
The procedure for neurological assessment involves assessment through the five criteria including mental
status testing , checking cranial nerves, followed by muscle strength, tone and bulk, reflexes, coordination,
sensory function and finally gait. The procedure requires determination of the neurological system that are
affected. This procedure helps to screen the discrete abnormalities in patients at risk for the development of
neurological disorders. In order to do so it is required to built in confidence to perform the exam. The
technologies like the neuro-imaging (e.g. CT, MRI) are utilised in this test. The exam findings make a strong
case for the presence of a pathologic process, even if it is not seen on a particular radiological study in such
examinations (Nursing and Midwifery Board of Australia. 2016).
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
6 of 29

Paraphrase This Document

Need a fresh take? Get an instant paraphrase of this document with our AI Paraphraser

Uncontrolled Copy If Printed
3. You are now asked to complete an admission document for Mr Bott. Considering Mr Bott’s age,
cultural, spiritual and religious data, identify six (6) ways in which these could be addressed in a plan
of care.
The six ways to provide a culturally competent care plan will involve:
Cultural awareness as the patient here is a Muslim English therefore care should be provided to conduct
assessment of the background before using any plan.
There should be presence of cultural knowledge of the different ethnic groups.
There should be cultural skill so that the nurses have the ability to collect relevant data regarding the
present problem of the patient and perform an assessment that is accurate and specific
There should be a cultural encounter so that the nurses can engage in cross-cultural interactions with
patients from culturally diverse backgrounds.
Finally there should be a cultural desire for motivating the professional to become aware more culturally
and to seek encounters in terms of culture (Santamaria et al. 2015)................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
4. As a result of the (R) sided hemiplegia, Mr Bott requires assistance to empty and change his
colostomy bag. Outline the steps involved (for the nurse) to change the colostomy bag (100 words –
bullet points acceptable)
1. Changing the colostomy bag requires few steps
 First making sure that every required objects are present
 Washing the hands
 Supporting the skin with one hand, slowly and gently easing the pouch off
 Emptying the used pouch by cutting the bottom part of the pouch
 Pouch should be put in the disposal bag (Santamaria et al. 2015)
2. Cleaning of the stoma area:
 Using of the plain but warm water for dry wiping the area surrounding the stoma
 The skin should be dried thoroughly with the dry wipe
 Placing used wipes in the disposal bag
 Washing the hands properly
3. Application of the next colostomy bag
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
8 of 29

Uncontrolled Copy If Printed
 Nurses can use a skin barrier for protecting the skin and providing proper idea base for adhesion of
the next colostomy bag
 The nurse might also need to cut hole in the stoma pouch flange for making kit of the correct size
 Removal of the protective cover from the adhesive flange
 Covering the adhesive with the help of hands for 30 to 50 seconds
 Warmth will increase the adhesion to the skin
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
5a) Outline 3 risk factors associated with immobility, providing a brief explanation of each one chosen.
(Bullet points are acceptable when accompanied by an explanation (100 words
 Due to immobility, the patient might have pressure sores. Prolonged pressure may get applied to the skin due
to the reason of immobility. This can lead to breaking of the skin and might have potential complication for skin
infection
 Due to immobility, the patient might have deep vein thrombosis. Researchers are of the opinion that its risk
increases after stroke after restriction of mobility. Blood clot might occur in the deep veins of the body causing
leg pain, swelling and giving the patient a hard time.
 Due to his immobility, the patient will not be able to maintain his daily activities of life like bathing, cooking,
cleaning, dressing and many others. This will impact his daily life. Moreover, he will also not be able to release
his urine in the correct time increasing chances of urine incontinence.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
9 of 29

Uncontrolled Copy If Printed
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
5b) Which assessment tool will need to be completed before Mr Bott is moved? (50 words)
The Falls Risk Assessment Tool (FRAT) can be used to assess the mobility capability of the patient. It mainly has 3
important parts. These are the Part 1 - falls risk status; Part 2 – risk factor checklist; and Part 3 – action plan. Part 1
has four sections to be analyzed to screen the chances of fall. Part 2 has 9 conditions where the status of the patient
in the conditions is analyzed. Part 3 is mainly based on the action plan.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
5c) Mr Bott has agreed to sit in his chair for lunch. Identify six (6) factors that the nurse will need to
consider before assisting with mobilisation. (150 words – bullet points acceptable only when
accompanied with a brief explanation of each).
 Before mobilising, nurse would check for spinal clearance
 Suspected DVT or PE should be checked
 Extreme confusion, and agitation of the patient should be checked
 Vital signs should be measured (Santamaria et al. 2015)
 Fall assessment chart should be documented along with consultation with physiotherapist
 The patient should be kept informed
 Number as well as safety needs of the staff should be measured
 Considering the availability of the lifting equipment.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
6a) After review by the speech pathologist, Ms Bott is no longer Nil by Mouth (NBM) and has been placed
on a modified diet. Identify and provide an example of each of the 3 (three) levels of modified foods
and fluids that are recommended to clients with dysphagia (100 words)
1. fluid
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
10 of 29

Secure Best Marks with AI Grader

Need help grading? Try our AI Grader for instant feedback on your assignments.

Uncontrolled Copy If Printed
 Mildly Thick Level 150, here the fluid will run smoothly off the spoon but will leave a mild coating on
the surface of the spoon
 Moderately Thick Level 400, here fluid will slowly drip in the form of dollops from the end of the spoon
(Black et al. 2015)
 Extremely Thick Level 900, here fluid will sit on the spoon and will not flow
2. Food
 Texture A – Soft, here texture of the food is soft naturally or it might be cooked or cut for altering its
texture
 Texture B - Minced and Moist T, here food is soft and easily smashed with the help of the fork. The
lumps here are smooth and rounded
 Texture C - Smooth Pureed, food is free from lumps, it is moist and smooth and have a grainy quality
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
6b) Provide 4 examples of ways in which the nurse can promote Mr Bott’s dignity and independence
during his lunchtime meal. (Each point must be accompanied by an explanation 100 words)
 The patient would be given the preferences to choose their likely food from a range of experiences so that
they do not feel forced to eat particular type of food (Dealey et al. 2015)
 The patient should be given privacy during the time of the food although informal communication during the
time can help in boosting his confidence
 The patient should not be forced to complete the food if he cannot complete it
 The food should look tasty so that the patient develops the appetite to have it
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
11 of 29

Uncontrolled Copy If Printed
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
7a) During the afternoon, Mr Bott indicates that he wishes to lie down. Once Mr Bott is lying down you
notice that his right heel is red and non-blanching.
Identify a type of screening assessment, commonly used in the prevention and management of
pressure injuries. Provide a brief explanation of the assessment tool you have chosen.
.........................................................................................................................................................................
The ulcer risk assessment tool can be used here fore pressure injury. To use this the factors of sensory,
moisture, activity, mobility, nutrition and friction needs to be considered. This tool uses the Braden scale
which consists of the above mentioned factors. According to this scale, scores are provided from 1 to
4.these scores are then interpreted as being low or high scores according to the total of which the action is
taken. ..............................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
7b) What are the extrinsic and intrinsic factors that cause (or contribute) to the formation of pressure
areas/decubitus ulcers? (50 words)
.........................................................................................................................................................................
The intrinsic factors include immobilization, cognitive deficit along with chronic illness like diabetes mellitus,
in addition to poor nutrition, use of steroids, and aging. The extrinsic factors include pressure, friction, along
with humidity, and shear force..........................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
7c) Present a list of strategies specific to Mr Bott’s care, to prevent further pressure injury. (50 words)
.........................................................................................................................................................................
The following prevention strategies should be considered for patients at risk:
 Prevention of friction and shearing forces while the positioning and transfers. There is a need to
lower bed head before repositioning the patient.
 There is a need to reduce moisture. This can be done by applying barrier cream.
 Skin Inspection is needed
 Positioning and repositioning should be carried
 Relieving pressure is very important.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
7d) Discuss whether or not the indication of a pressure injury would require you to collaborate with any
other health professional. In your answer, provide details of the text within the Enrolled Nurse
Standards for Practice which directly relates to decision making. (100 words)
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
12 of 29

Uncontrolled Copy If Printed
.........................................................................................................................................................................
According to the Enrolled Nurse Standards for Practice, the domain of professional and collaborative practice
involves that the nurses’ functions in accordance with the law in addition to the policies and procedures affecting EN
practice. The practises nursing in a way should be able to ensure that the right in addition to the confidentiality, dignity
and respect of people are held upright and they should take steps to accept accountability and responsibility for their
own actions. In accordance to this the nurses might involve in collaborative practises with other professionals by
following these standards (Luk and Loke 2015). .................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
13 of 29

Paraphrase This Document

Need a fresh take? Get an instant paraphrase of this document with our AI Paraphraser

Uncontrolled Copy If Printed
7e) Provide an example of a progress note entry for your client to indicate the presence of the new
pressure injury to the right heel, include any strategies you have put in place to prevent further injury
(50 words)
22.45 hrs – vitals- normal
Exam- pressure injury on the right heel
Med- no new medications
Assessment- right heel red and swollen
Plan- strategies for avoiding friction ................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
8a). What is the nurse’s role in the discharge planning of Mr Bott? In your answer include:
• when the discharge planning process should commence
• the members of the multidisciplinary team that should be involved
• any community services he may require
(min 100 words)
.........................................................................................................................................................................
Discharge planning carried out at admission by nurses plays an important role in improving patient
outcomes, however there are policies in place to maintain effective discharge planning whi h is the duty of
the nurses to follow them. Completion of discharge planning is important for the safe transition of patients
from one care setting to the next and the nurses must ensure this. A more prominent comprehension of
attendants' release arranging practice in intense care wards is required. More prominent joining of release
arranging exercises into medical attendants' every day practice may likewise happen if attendants are
engaged with the improvement and execution of the release procedures and afterward furnished with
instruction and customary criticism on month to month review results.............................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
8b) Being unwell and receiving care for even a period of time can result in increased risk and
complications to the client. Provide 4 examples of those risks or complications. (50 words)
The common complications involve the hospital risks of medication error. The second problem is high
chances of getting hospital acquired infections. The third complication is pneumonia, which often occurs
during long stays at hospitals and especially after surgery and finally there is complication of deep vein
thrombosis that is one of risks after surgery.....................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
14 of 29

Uncontrolled Copy If Printed
9) After 5 weeks on your ward Mr Bott is preparing to be discharged when his condition deteriorates.
You come onto the night shift and in handover hear that Mr Bott is unwell. He is febrile at 38 degrees
and has IV hydration in progress. Mr Bott’s fluid input and output are being monitored. Mr Bott’s right
heel has now broken down and he has been complaining of pain when he coughs.
You approach the bedside to review your client. Discuss at least 6 factors that you will you need to
consider at the beginning of your shift. Include an explanation of why with each? (150 words bullet
point list is acceptable)
.........................................................................................................................................................................
 At the beginning of the shift there is a requirement to go through the vitals of the patient, as it will tell
about the present status
 The medication chart needs to be assessed so that the right medication can be given during the
shift hours to the patient
 Assessment for the broken hip is required
 The fluid input and output chart needs to be checked to understand the fluid intake and output of the
patient.
 The patient should be tried to be made comfortable ............................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
10a) Mr Bott has developed a chest infection, he slowly and with difficulty explains to you that he does not
wish to take antibiotics and wishes to be left to die in peace. Evaluate the role of the nurse in this
situation, including the legal aspects of refusal of treatment. (200 words)
It will be the role of the nursing professional to indulge into the therapeutic relationship with the patient. Via
indulging in the therapeutic relationship, a nurse will try to explain why taking medication and getting cure is
a healthy option apart from choosing the euthanasia(Grace and DRN 2017). Developing therapeutic
relationship will also help the nurse to understand the exact mental consequence underlying Mr Bott’s
refusal of treatment. This understanding will subsequently help in devising person-centred care plan for Mr.
Bott.
Under the legal aspect to the case study, it can be said that it is the duty of the nursing professional to
respect the autonomy of the patient. However, respecting the autonomy of Mr. Bott in this case will
result in choosing the option for euthanasia. Active voluntary Euthanasia is permitted only in the
Northern Territory of Australia under strict legal circumstances. So euthanasia in case of Mr, Bott will
not be an option. So, it will be the duty of the nurse of act under best interest of Mr. Bott. Here the
ethical principal of autonomy will be over-ruled under the justification of the ethical norm of non-
maleficence (causing no harm to the service users)(Grace and DRN 2017). This is again supported
by the standard 1 of professional practice of NMBA which promotes critical thinking and providing
comprehensive care.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
16 of 29

Secure Best Marks with AI Grader

Need help grading? Try our AI Grader for instant feedback on your assignments.

Uncontrolled Copy If Printed
PART B - Care Plan
1a) Identify and name the National Safety and Quality Health Service Standard which focuses on
responding to clinical deterioration (25 words)
The identified standard is “Recognizing and Responding to Acute Deterioration”. It mainly describes the systems as
well as the procedures that help in responding effectively to the patients during the time when their mental, physical
and cognitive capability deteriorates.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
1b How will an enrolled nurse make sure that any new information or changes in the required treatment
or care of a client are recorded and implemented into the client’s care plan? (25 WORDS)
the three steps under this standard needs to be maintained. These are recognizing acute deterioration, escalating the
care and responding to the deterioration. Immediately after documenting the deterioration, it should be
incorporates in electronic health records and immediately the nurse should then escalate it to the immediate
team present on the ward, take their support and consult a physician or senior nurse to ensure the patient gets
out of danger.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
1c) You have monitored Mr Bott’s care plan and in consultation with the registered nurse, the pressure
injury to the right heel is added to the care plan below. A week later, there is no further evidence of
breakdown and the redness on the right heel has reduced. Complete the evaluation by adding at least
3 additional points.
Evaluation of moisture presence on the skin
Evaluation of redness on the skin
Evaluation of skin texture and further chances of skin issues in future
Sample care plan:
Assessment Nursing Problem Goals/Expected
Pt Outcomes
Intervention Evaluation
Subjective data:
Decreased
mobility
Objective data:
Redness to right
heel
Impaired Skin
Integrity Stage 1
superficial pressure
injury, indicated by
non-blanching,
redness that does
not subside after
pressure is relieved
Within 2 weeks
Clean intact skin
Pressure relief is
provided by
position change
and pressure
relieving
mattress
Pt will be turned and /or positon
changed every two hours as
evidence by nursing
documentation
Mobilise twice daily (as per
mobility care plan)
Conduct a full skin inspection
twice daily paying close attention
to the skin directly over bony
prominences
Bed linen to be kept clean and
wrinkle free
By the end of
day 7 there is
reduced
redness over
the
right heel
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
18 of 29

Uncontrolled Copy If Printed
Nutritional intake
is appropriate
Reduction of moisture to the skin
Monitor nutritional intake with a
daily food chart
Offer hourly fluids whilst awake
Use manual handling aids to
prevent friction and sheering
Use sheepskin boots for comfort
and to reduce sheer
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
19 of 29

Paraphrase This Document

Need a fresh take? Get an instant paraphrase of this document with our AI Paraphraser

Uncontrolled Copy If Printed
CASE STUDY 2
Ella is a 6-year-old girl who has cerebral palsy who had been brought into hospital with a chest infection.
You have been asked to perform a health assessment for Ella who is distress at being in hospital.
Cerebral palsy can cause different degrees of developmental delay but in order to understand the impact
the condition has on a person you need to be aware of the stage of growth and development a person
should be at.
1)Discuss the stage of human growth and development that you would expect Ella to be at as a six-year
old? (min 100 words)
1.Growth and development at 6 years old can be enlisted as follows:
 Speak in complete sentences with 5 to 7 words
 Could be able to follow a set of three or more commands altogether
 They end up understanding that one word can have more than one meaning which makes them
absorb jokes
 They should be able to read books that are at par with their age
 They should be able to decode an unknown word
 They must be able to concentrate on a piece of work for at least 15 minutes
 They should understand the difference in directions, from left to right
 They should understand the difference between day and night
 They must be able to repeat at least 3 digits backwards
 They must be able to tell what is the time
Developmental changes:
 Temporary milk teeth starts to fall off and is replaced by permanent teeth
 Children at this age grow almost 2.5 inches a year and 4-7 pounds a year
 A body image starts developing
 Body awareness leads to feelings common stomach ache, etc. in their body
2)
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
20 of 29

Uncontrolled Copy If Printed
2a) Refer to the Person Centred Health Care Assessment and the Development of Health Care Plans
Core Standards for Practitioners to answer this question.
Identify at least six (6) potential health issues associated with cerebral palsy.
Six associated health issues associated with cerebral palsy:
 Seizures or fit: At least 35% of the children affected with cerebral palsy experience seizures or fits primarily
caused due to electrical impulse mishap in network in the brain
 Dysphagia: Children affected with cerebral palsy experience this condition which leads to difficulty in
swallowing primarily due to poor muscular and motor function control
 Oral health issues: It causes oral problems such as excessive gagging and gingivitis. It also leads to cheek
and tongue biting on involuntary basis.
 Vision issues: Increased risk of cerebral vision impairment (on account of brain damage), hyperopia or
strabismus
 Cognitive behavioral issue: cognitive impairment is extremely common in cerebral palsy children, however it
should be noted that not all children suffer from similar complications
Respiratory issue: issues in swallowing and excessive drooling. Along with these issues there might be issues
with coughing and blocked airways also lead to respiratory issues
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
2b) List the four (4) essential skills that you need to draw upon when completing a health care
assessment on Ella?
.........................................................................................................................................................................
Four important skills required to successfully assess a patient with cerebral palsy can be mentioned as follows:
 The nurse doing the assessment must have a little knowledge about speech therapy
 It is also important for the nurse to have a little knowledge about physical therapy
 The care giver must be extremely patient because handling kids with cerebral palsy can be extremely
challenging
 The care giver must be able to emotionally connect with the child and at the same time offer assistance
making sure that the patient can be comfortable round the care giver.
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
21 of 29

Uncontrolled Copy If Printed
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
2c) Identify at least six (6) components of a comprehensive care health plan and provide the reasons why
they are included in a person’s plan?
.........................................................................................................................................................................
Six components of a comprehensive health care plan:
 Impaired mobility: Assistance to improve the mobility of the patient using external support of wheelie walker in
order to help the patient move with comfort
 Imbalanced nutrition: Constant monitoring of small and frequent meals throughout the day and provide fluid
intake. High protein supplements and soft and blended food should be administered to the child.
 Impaired verbal communication: Patiently understand the unspoken words and provide ample time for the
child to respond. Distractions such as television and radio should be kept at the minimum.
 Ineffective therapeutic regimen management: Educate the family to take proper care of the child and
encourage the siblings to take care of the child.
 Risk of Injury: Explain the parents about factors that can trigger a seizure and provide a safe environment to
the child
 Risk of delayed growth and development: Explore the feelings of the family about child’s development and
provide a positive and safe homely environment in the family.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
3) Ella becomes more distressed as you are performing the health care assessment. Using problem
solving strategies and techniques, discuss the actions you could take to reduce Ella’s distress. (min
100 words)
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
22 of 29

Secure Best Marks with AI Grader

Need help grading? Try our AI Grader for instant feedback on your assignments.

Uncontrolled Copy If Printed
Steps taken to pacify Ella:
Ella could be pacified by making her feel comfortable within the hospital environment and at the same time
encourage the parents to make her feel at home. The nursing professional should be extremely compassionate and
friendly while dealing with the child and at the same- time as these children are susceptible to seizures, care should be
taken to keep the stimuli causing seizures under check.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
23 of 29

Uncontrolled Copy If Printed
You speak with Ella’s mum, Karen, who is staying in hospital with Ella and she tell you that their family like
to take a wellness approach to health.
4) Explain what a wellness approach to health means and provide at least 3 examples of how a wellness
approach could be used for Ella. (min 100 words)
Wellness approach for Ella:
Wellness approach for Ella would include proper monitoring of food and water intake, involvement in
occupational activities and proper education of the family members so as to make her family members aware about
her day to day hardships that she faces with her slowed development and growth ability.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
5) As a family with a young child, identify some of the family health care needs that Ella and her family
may require. (min 50 words)
Family health care needs:
Family health care needs would include proper counseling of the family members in order to make them
aware that there are many other children like Ella who are victims of cerebral palsy and can be provided a positive and
safe environment at home. This could be further achieved by educating the parents to assist the child with the delayed
development, giving ample amount of time to respond and choosing the right kind of toys for the child and helping the
child with activities of daily living so that the child is able to take ownership of her own actions.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
24 of 29

Uncontrolled Copy If Printed
6) When checking Ella’s vital signs one afternoon you note that her respiratory rate has increase from 22
to 32 and that her SpO2 has decreased from 98% to 92%. Identify what actions you would take. In
your answer, discuss the following:
 who you would inform of Ella’s condition
 what clinical signs suggest that there is a deterioration in Ella’s condition. (min 50 words)
6a) The abnormalities in Ella’s vital signs would be informed to the primary care physician on an immediate
basis and at the same time the information would be conveyed to Ella’s family members. Further based upon
the clinical decision undertaken procedure such as artificial administration of oxygen or bronchodilation could
be taken in order to help Ella find quick relief
6b) The respiratory rate is extremely high, from 22 breaths per minute to 32 breaths per minute which is not a
positive sign and signifies the presence of some form of infection in the lungs.
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
CASE STUDY 3
Sandra is a 42-year-old woman who has been admitted to hospital for some investigations as she has been
trying for some time to become pregnant. Sandra has a 14-year-old son from a previous marriage.
1) Identify at least 3 possible causes for infertility.
The first cause behind her infertility is her age. According to Masoumi et al. (2015), women are born with
fixed number of ages so as they ages, the total number eggs in the stock declines. A women’s infertility
start to decline by early to mid-30s and by the age of 35, the fertility is dropped by 40%. By the age of 40,
woman’s fertility declines further since Sandra is 42 years old, her fertility might have decreased due to her
age.
Second cause behind her infertility might be due to polycystic ovarian syndrome (PCOS). This syndrome
results in an imbalance in the ovarian cycle and thereby causing anovulation (Masoumi et al. 2015).
The third cause might he gain in weight. Though the exact weight of Sandra is not mentioned in the case
study but according to Masoumi et al. (2015) women after their first pregnancy tends to gain weight leading
to decrease in the overall fertility. Over-weight or obesity interferes with the menstruation and ovulation
leading to infertility.
The fourth possible cause of infertility in case of Sandra might be endometriosis, a condition where the
tissue that lines the uterus (endometrial tissue) grows in other parts of the body like pelvis. The over-growth
damages endometrial tissue and the lining of the uterus and thereby causing subsequent inflammation and
irritation leading to infertility (Masoumi et al. 2015).
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
25 of 29

Paraphrase This Document

Need a fresh take? Get an instant paraphrase of this document with our AI Paraphraser

Uncontrolled Copy If Printed
2) Discuss the impact of infertility on Sandra. In your answer ensure that you cover the physical,
emotional and psychosocial impacts. (min 100 words)
The psychological impact of infertility on Sandra might include reduced self-esteem and feels of failure.
According to Hasanpoor et al. (2014), women who are unable to get pregnant or are suffering from the
impending causes of infertility experiences high psychological turmoil like a feeling of regret and getting
upset on hearing the pregnancy of other women.
The emotional impact of infertility on Sandra might include grief, depression and regret. The study
conducted by Hasanpoor et al. (2014) highlighted that the emotional impact of infertility include loneliness,
fear and anxiety from the disclosure of infertility. Both the emotional and the psychological impact of
infertility will hamper the mental health and well-being of Sandra.
The physical impact infertility includes massive weight gain, difficulty in sleeping and increase in the blood
pressure. All these physical outcomes of infertility which might hamper the health and well-being of Sandra
is linked with her mental health. Increase in level of stress of depression leads to increase in the blood
pressure or state of insomnia which hampers the physical equilibrium of the body. Depression is also
associated with extra consumption or poor consumption of food which might result in malnutrition or
excessive gain in weight(Luk and Loke 2015).
3) When talking to Sandra about her family, she mentions that her son, Dean, has been very moody
lately and is difficult to talk to. What information about adolescent growth and development could you
share with Sandra? (min 100 words)
I will inform Sandra that since his son Dean is 14 years old, he is in his pubertal stage. At this age there
occurs change in the regulation of the sex hormones. In case of Dean it will be male sex hormones like
testosterone. Testosterone apart from causing sexual development, also leads to emotional changes and
thereby resulting in mood swings(Arain et al. 2013). Moreover, I will also enlighten Sandra about the
Erikson’s stages of psychological development which states that age between 13 to 21 years is brimmed
with the psychological crisis which results in identity Vs Role confusion. This identity versus role confusion
causes mood swings (Blatt and Bless 2013).
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
26 of 29

Uncontrolled Copy If Printed
4) When Sandra’s son visits, you notice that he is physically very similar to his mother, they both have
red hair, blue eyes, freckles and both are tall.
Discuss the influence of both genetics and the environment on growth and development. (min 100
words)
The physical similarity of Sandra’s son with Sandra signifies that the dominate genes of physical
appearance which was present within Sandra were expressed in his son’s and resulting is astonishing
physical similarity of Sandra with her son. This also highlights that Sandra somatic genes are dominant and
resulting in homozygous autosomal domain expression(Sjouke et al. 2014).
In the environmental influence of growth, has no direct relation to the physical appearance but on the
psychological or emotional well-being. Since, Dean is Sandra’s son from previous marriage, Dean might
experience identity crisis with his new father (half-father) and thereby resulting is change in his emotional
and psychological development(Blatt and Bless 2013).
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
27 of 29

Uncontrolled Copy If Printed
References
Arain, M., Haque, M., Johal, L., Mathur, P., Nel, W., Rais, A., Sandhu, R. and Sharma, S., 2013. Maturation
of the adolescent brain. Neuropsychiatric disease and treatment, 9, p.449.
Blatt, S.J. and Bless, R.B., 2013. A Dialectic Model of Personality Development. Development and
vulnerability in close relationships.
Grace, P.J. and DRN, P. eds., 2017. Nursing ethics and professional responsibility in advanced practice.
Jones & Bartlett Learning.
Hasanpoor-Azghdy, S.B., Simbar, M. and Vedadhir, A., 2014. The emotional-psychological consequences
of infertility among infertile women seeking treatment: Results of a qualitative study. Iranian journal of
reproductive medicine, 12(2), p.131.
Luk, B.H.K. and Loke, A.Y., 2015. The impact of infertility on the psychological well-being, marital
relationships, sexual relationships, and quality of life of couples: A systematic review. Journal of sex &
marital therapy, 41(6), pp.610-625.
Masoumi, S.Z., Parsa, P., Darvish, N., Mokhtari, S., Yavangi, M. and Roshanaei, G., 2015. An
epidemiologic survey on the causes of infertility in patients referred to infertility center in Fatemieh Hospital
in Hamadan. Iranian journal of reproductive medicine, 13(8), p.513.
Nursing and Midwifery Board of Australia. 2016. Registered nurse standards for practice. Access date: 10th
September 2018. Retrieved from: https://www.nursingmidwiferyboard.gov.au/codes-guidelines-
statements/professional-standards/registered-nurse-standards-for-practice.aspx
Sjouke, B., Kusters, D.M., Kindt, I., Besseling, J., Defesche, J.C., Sijbrands, E.J., Roeters van Lennep, J.E.,
Stalenhoef, A.F., Wiegman, A., de Graaf, J. and Fouchier, S.W., 2014. Homozygous autosomal dominant
hypercholesterolaemia in the Netherlands: prevalence, genotype–phenotype relationship, and clinical
outcome. European heart journal, 36(9), pp.560-565.
Black, J., Clark, M., Dealey, C., Brindle, C. T., Alves, P., Santamaria, N., and Call, E. 2015. Dressings as an
adjunct to pressure ulcer prevention: consensus panel recommendations. International wound
journal, 12(4), 484-488.
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
28 of 29

Secure Best Marks with AI Grader

Need help grading? Try our AI Grader for instant feedback on your assignments.

Uncontrolled Copy If Printed
Dealey, C., Brindle, C. T., Black, J., Alves, P., Santamaria, N., Call, E., and Clark, M. 2015. Challenges in
pressure ulcer prevention. International wound journal, 12(3), 309-312.
Santamaria, N., Gerdtz, M., Sage, S., McCann, J., Freeman, A., Vassiliou, T., ... and Knott, J. 2015. A
randomised controlled trial of the effectiveness of soft silicone multi‐layered foam dressings in the
prevention of sacral and heel pressure ulcers in trauma and critically ill patients: the border
trial. International wound journal, 12(3), 302-308.
Santamaria, N., McCann, J., O’Keefe, S., Rakis, S., Sage, S., Tudor, H., ... and Ng, F. M. 2015. Clinical
innovation: results from a 5-year pressure ulcer prevention project in an Australian university. Wounds
International, 6(3), 12-16.
11890144429009757860.docx Ver. 1.1 (21/12/2015) © TAFE Queensland 2024
29 of 29