Holmesglen Diploma of Nursing: HLTENN005 Workbook Assessment Task 4/5

This document presents a completed workbook assessment for the HLTENN005 unit, focusing on contributing to nursing care for a person with complex needs. The scenario centers on Jessica Fong, a 30-year-old patient who sustained multiple injuries in a motor vehicle accident, including a closed head injury, fractured tibia and fibula, and a perforated bowel requiring a laparotomy and loop ileostomy. The assessment covers various aspects of nursing care, including post-operative management, neurological and neurovascular observations, ileostomy and stoma care, nasogastric tube (NGT) feeding, and addressing the patient's physical, emotional, and psychosocial needs. The student answers questions related to nursing interventions, maintaining patient dignity, assessing and managing complications associated with the ileostomy, and providing education to the patient. Additionally, the assessment includes the rationale for nursing interventions like head elevation, managing anxiety, and ensuring regular mouth care for patients with NGT feeds. The student demonstrates understanding of the conditions for assessment, equipment and resources required and post-operative orders given to the patient. The student is expected to answer all questions fully with explanations related to the scenario given.

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Assessment Task 4/5: Workbook Assessment
Student Version: Knowledge
Student information
Student name: . Student ID: .
Section A – Program/Course details
Qualification code: HLT54115 Qualification title: Diploma of Nursing
Unit code: HLTENN005 Unit title: Contribute to nursing care for
a person with complex needs
Section B – Assessment task details
Assessment number: 4/5 Semester/Year: Semester 1 2019
Due date: To be provided by your
Assessor.
Duration of assessment: 2 tutorials
Assessment task
results:
This assessment task will be marked as:
☒ Ungraded result: Satisfactory or Not Satisfactory
☐ Other (eg points): Graded once deemed satisfactory
Section C – Instructions to students
Task instructions:
 Worksheet will be completed over two tutorials.
 Students will need to access resources on Brightspace such as readings and PowerPoints to work on
worksheet outside of tutorials.
 Students MUST answer all questions fully (explanations relating specifically to the scenario is required).
 Answers for the worksheet will be covered in the tutorials.
 Completed worksheets will be returned to the session teacher.
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Section D – Conditions for assessment
Conditions:
Student to complete and attach Assessment Submission Cover Sheet to the completed Assessment Task.
Equipment/resources students must supply: Equipment/resources to be provided by the RTO:
 Recommended text:
Koutoukidis, G, Stainton, K, & Hughson, J. (2017).Tabbner’s Nursing Care Theory and Practice (7th ed,).
Sydney, Australia: Elsevier.
Tiziani A, 2013 Havard’s Nursing Guide to Drugs (10th
ed.). Mosby Elsevier
 Pens
 Assessment paper
 Resources on Brightspace and face to face
discussion facilitated by a teacher.
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Student Instructions
Read the following Scenario and answer the questions using the information provided below.
Scenario:
Jessica Fong is an active thirty (30) year old who was involved in a motor vehicle accident. She has
sustained a closed head injury, and a fractured right tibia and fibula, which required an ORIF (open
reduction and internal fixation). Her other injury is a perforated bowel. She has had a laparotomy and loop
ileostomy formation. Jessica has a NG tube (Nasogastric tube) inserted prior to surgery, it remains insitu for
nasogastric feeds to meet her nutritional needs.
Medical history: No significant medical history. Allergy to strawberries causes abdominal pain and
diarrhoea.
You undertake a systems assessment of Jessica at the commencement of your care. These are your
assessment findings:
CNS: Alert, orientated, obeys commands. Slightly drowsy as she is post anaesthesia. Pupils size 3 and
reactive to light bilaterally. Full function and movement to both arms and left leg, right leg injured. No
complaints of pain due to analgesia given intra operatively.
CVS: Temp. 36.7C, HR 88 bpm regular. Colour, god well perfused. Peripheries warm. IV(Intravenous)
cannula site intact.
Resp: Air entry L(left)=R (right). RR 18rpm. SaO2 = 97% on room air
Renal: Has not passed urine since return to ward one (1) hour ago. Pre-operative urinalysis NAD (No
abnormalities detected), SG (Specific Gravity) 1.010, Ph (acid-alkali balance) 5.5
GIT: Ileostomy bag 75mls rose coloured fluid. Stoma red. Abdomen soft, no distention.
Endocrine: BGL (Blood glucose level) = 6.5 mmols
Musculoskeletal: Neurovascular assessment – left leg full range of movement and sensation. Right leg,
Jessica is able to wriggle her toes, no other movement due to operation site. Has full sensation on right leg.
Both legs pedal and tibial pulses strong. Capillary refill under 2 seconds both feet. Legs warm and well
perfused.
Skin: No redness or loss of skin integrity
Social: Divorced, has sole custody for her seven (7) year old daughter. Has no contact with ex-husband
and receives no financial help for their daughter. She works full time in a pharmacy and has limited child
care assistance from her parents who also both work. She is very anxious about the impact of her injuries
on her ability to return to work and care for her daughter.
Post-operative orders:
 RPAO (routine post anaesthetic observations)
 Neurologic and neurovascular observations 4/24 prn
 Nurse with head elevated to 40%
 RIB (rest in bed) until surgical and physiotherapy review in 24 (twenty-four) hrs. Mobilise with a
walking frame after review.
 Abdominal wound dressing remains intact until surgical review.
 Ileostomy and stoma care prn (as necessary) as per protocol
 NGT (Nasogastric tube) gravity feeds 50mL/hour of Osmolite
 NBM (Nil by mouth) until bowel sounds return.
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Element 1: Perform nursing interventions to assist a person with complex needs
1.11.2 Perform nursing interventions based on the person’s predetermined plan of care
Question
1.1a
Jessica sustained a closed head injury and is to be nursed
with her head elevated by 40 (forty) degrees. Explain why
this is important.
Satisfactory response
Yes ☐ No ☐
Answer:
Head injury leads to alteration of pressure in the cranium, cerebral perfusion pressure
and the blood flow to the cerebrum. Closed head injury increases the intracranial
pressure and elevation of the head at 40 degrees therefore decreases the intracranial
pressure building up and the cerebral perfusion pressure as well.
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Teacher Comment:
Question
1.1b
If Jessica’s neurological observations deteriorate for
example her conscious level decreasing, pupil’s unequal
and reacting sluggishly. What complication could this
indicate?
Satisfactory response
Yes ☐ No ☐
Answer:
………………………………………………………………………………………………………
……An increase in Intracranial Pressure.
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Teacher Comment:
Question
1.1c
Why is it of neurological importance to manage Jessica’s
anxiety, pain and continence needs? Satisfactory response
Yes ☐ No ☐
Answer:
……To manage Jessica’s stress. Anxiety can lead to urinary incontinence hence
management of continence needs is required for a neurological impaired disorder.
Management of pain is done to make Jessica comfortable.
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Teacher Comment:
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1.3 Undertake nursing interventions demonstrating respect for the person’s dignity and cultural diversity.
Question 1.2 Jessica is at bedrest for 24hrs and is reliant on you for her
personal hygiene, continence and pressure care needs. She
is a young independent person, explain three (3) strategies
you would employ to maintain her dignity and respect her
individuality.
Satisfactory response
Yes ☐ No ☐
Answer:
………………………………………………………………………………………………………
…Ensuring that she remains covered while providing her care needs. By doing so it
protects her physical privacy.
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Protecting Jessica’s personal information by avoiding sharing personal information about
Jessica beyond what is necessary for the members of the care team.
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Assisting Jessica with personal grooming , this will make her retain pride in her
appearance.
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Teacher Comment:
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1.3 Encourage the person to assist by undertaking aspects of their own care during care interventions
Jessica may be going home with her ileostomy bag before she has her reversal surgery. You are going to
assess her ileostomy and at the same time educate Jessica regarding self-management.
Question
1.3a
Discuss assessments you would make regarding the following,
include Jessica’s involvement in your answer. Satisfactory response
Yes ☐ No ☐
Answer:
 Peri-stomal skin:
 ……………………………………………………………………………………………………I
will remove Jessica’s pouching system
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Assess Jessica in both her sitting and lying positions.
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…
 Stoma:
 …I will assess for the state and colour of the stoma by feeling surrounding stoma site
gently for tenderness.
 I will then ask Jessica to cough and feel the cough impulse to assess for parastomal
hernia.
 I will then gently digitate the stoma to check patency and assess the stoma.
Teacher Comment:
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 ………………………………………………………………………………………………………
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 Stoma bag:

 ……………………………………………………………………………………………………I
will start in the in centre of the stoma and assess outward ending with the
surrounding tissue..
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Question
1.3b
Jessica is at risk of a number of complications arising from
her stoma. Choose two (2) complications and discuss the
education you would provide to Jessica using the table
provided.
Satisfactory response
Yes ☐ No ☐
Answer:
COMPLICATION SIGNS &
SYMPTOMS/APPEARANCE
MANAGEMENT
Peristomal infection.
Itching, discomfort and
pain. (Steinhagen, E.,
Colwell, J., & Cannon,
2017)
After Jessica baths with
the pouch she should dry
the skin and the pouching
system carefully.
Teacher Comment:
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Stoma trauma. A visible cut, and a bright
red bleeding.
Manage the visible cut
while observing the
the aseptic techniques
to prevent infection.
1.4 Consider the person’s physical, emotional and psychosocial needs when performing nursing
interventions.
Question
1.4a
Jessica is very anxious and distressed about having an
ileostomy. State three (3) reasons for her anxiety Satisfactory response
Yes ☐ No ☐
Answer:
1.
………………………………………………………………………………………………………
Jessica’s main fear and anxiety can be on the change of the diet she is to take due to the
procedure he has undergone lately.
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2. She might also be scared of the status of then stoma. “what if her stoma
Teacher Comment:
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leaks?”………………………………………………………………………………………………
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3.According to Liao & Qin, (2014.), it was said that in as much as the individual with
stoma has to cope with some sensitive issues such as faecal incontinence, he/she may
also experience changes to their body image, sexual functioning, isolated socially, stigma
decreased mood and embarrassment.
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Element 2. Contribute to the nursing care of people with common disorders and conditions
2.1 Provide nursing care to the person appropriate to the management of complex conditions
Question
2.1a
Jessica had her Nasogastric tube (NGT) inserted prior to her
abdominal surgery, provide a reason for this procedure being
performed specifically pre-operatively.
Satisfactory response
Yes ☐ No ☐
Answer:
………………………………………………………………………………………………………
Inserting a nasogastric tubing helps in gaining access to the stomach and its contents
and it can be performed to drain the Gastric contents prior to abdominal surgery.
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Teacher Comment:
Question
2.1b
Would a NGT (Nasogastric tube) usually be contraindicated for
this person? If so, explain the reason. Satisfactory response
Yes ☐ No ☐
Answer:
……………………………………………………………………………………………………
…YES, it would be contra indicated, increase in hospital stay and complication rates are
observed in patients who receive nasogastric decompression compared to those
without NG tube (Wang et al.,2015).
.……………………………………………………………………………………………………
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Teacher Comment:
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NGT gravity feeds 50mL/hour of Osmolite has been ordered for Jessica.
Question
2.1c
How will you confirm nasogastric tube placement prior to
commencing nasogastric feeds?
Outline how you will deliver the feed after checking the tube
placement.
Satisfactory response
Yes ☐ No ☐
Answer:
Tube placement check:
………………………………………………………………………………………………………
ICorrect positioning of the NG tude can confirmed by the use of Chest X-Ray, the view
should be adequate with upper oesophagus down to below the diaphragm.
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Delivery of feed:
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According to Gale Encyclopedia of Nursing and Allied Health, (2016), the food can be
given by gravity, or by a pump.
Gravity requires the use of a syringe.
3 to 5 ml of air is therefore pulled into the syringe,
The syringe is then connected to the end of the tube,
A stethoscope is put in the nurses’s ears its end over the top of the stomach at a position
that is just below the center of the ribs.
The air is then pushed into the NG tube
Food contents are now pulled into the syringe and Jessica is fed.
The last thing after the feeding is over is flushing the tubing.
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Question
2.1d
Explain why regular mouthcare is important for a person having
nasogastric feeds. Satisfactory response
Yes ☐ No ☐
Answer:
………………………………………………………………………………………………………
……Regular Mouthcare improves the oral and dental hygiene and this can help prevent
bad breath. Effective oral care done to Jessica can help reduce ingection and
promotes health as well.
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…
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Teacher Comment:
2.2 Observe, report and document the person’s reactions and responses to the provided care management
and medication
Question 2.2 Jessica’s SpO2 drops to 87% on room air (RA). The doctor has
prescribed 6L/min of oxygen therapy via a Hudson face mask.
You have applied the oxygen therapy.
Provide three (3) immediate nursing interventions you may
initiate at this time for Jessica.
Satisfactory response
Yes ☐ No ☐
Answer:
1.……Position Jessica with her head elevated in a semi-Fowler’s position.
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2…I will turn Jessica every two hours while monitoring the oxygen saturation closely after
turning.
Teacher Comment:
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……… 3.Maintaining the oxygen administration device as stated by the by the physician
treating Jessica. This maintains the oxygen saturation equal to or above 90%. .
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2.3 Refer promptly to the registered nurse any reactions, responses or variations from the normal or
unexpected outcomes, including concern for the deteriorating patient.
Question 2.3a Jessica has been on oxygen therapy for four (4) hours,
periodically the oxygen has been removed to assess her ability
to maintain her SpO2 on RA, they drop below 90% when the
oxygen is removed. You report your findings to the RN and
Doctor.
It is decided to continue oxygen therapy for Jessica. What are
(two) 2 further nursing interventions you would initiate for long
term oxygen therapy?
Satisfactory response
Yes ☐ No ☐
Answer:
1.Reduce the work of breathing for Jessica by adopting a sitting position that will help her
breathe with ease. Such allowing her sit on the chair with a table in front of her,
then I will advise her to place her arms on the table and allow her relax her arms
and shoulders, instruct her to place her feet on the floor and breath as normal.
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2.Administer oxygen while Jessica is at rest and when asleep at 2L/min via the nasal
cannula.
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Question 2.3b
What is incentive spirometry?
Satisfactory response
Yes ☐ No ☐
Answer:
…The use of a medical device that helps in improving the functioning of patient’s lungs.
This device gently exercises the lungs keeping them as healthy as possible.
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Teacher Comment:
Question 2.3c
Outline how you would instruct a person to use the spirometer. Satisfactory response
Yes ☐ No ☐
Answer:
I will tell Jessica to sit up and hold the spirometer device,
place the mouthpiece spirometer in her mouth and ensure she seal the spirometer’s
mouthpiece with her lips nicely,
Instruct her to breath out normally then in but slowly, hold her breath for like 3 to 5
seconds then breath out again slowly.
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Teacher Comment:
Element 3. Use critical thinking to improve care quality.
3.1 Monitor own thinking constantly in relation to own clarity, precision, accuracy, consistency, logic and
significance of care, in order to correct oneself when appropriate in the context of caring for a person.
Question 3.1 Given that oxygen is considered as a medication,
Match the six (6) rights of oxygenation administration with the
nursing actions you would perform before administering oxygen
for Jessica?
Satisfactory response
Yes ☐ No ☐
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Answer:
Answer
Documentation F
A) Check the patient Identification band
with the Identification label on the
progress notes.
Route
D
B) Oxygen administered continuously
or intermittent with nebulisers.
Dose
C
C) The appropriate oxygen
administration device eg nasal
prongs 2-4l/min Hudson face mask
5-10l/ min
Time/ frequency E
D) Oxygen given via the nose / mouth.
Device
B
E) Oxygen rate in litres / minute
Patient
A
F) Check the Doctors orders in the
progress notes and document
oxygen administration in the
progress notes.
Teacher Comment:
3.2 Identify possible nursing interventions for a person with complex needs, based on health information and
clinical presentation.
Question 3.2 Jessica has not passed urine since returning from theatre two (2)
hours ago, and is now complaining of a full bladder and
abdominal discomfort. Urinary catheterization is an invasive
procedure and should only be performed when other strategies
have not worked.
Explain three (3) nursing interventions you would implement to
assist Jessica to empty her bladder.
Satisfactory response
Yes ☐ No ☐
Answer:
 1.I will help Jessica perform Kegel exercises to strengthen the pelvic floor muscles that
contract and relaxes muscles aiding voiding of the retained urine.
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 2.Provide privacy, this helps in relaxation of the urinary sphincters thus promoting urine.
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 .……………………………………………………………………………………………
 3. I will perform Credes maneuver. It increases urinary bladder pressure consequently
inducing relaxation of sphincter allowing voiding.
Teacher Comment:
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3.3 Raise the issue with the registered nurse where the nursing interventions are at odds with an already
prescribed course of action by multidisciplinary team.
Question 3.3 Despite the interventions Jessica is still unable to pass urine, you
inspect her abdomen which is distended, you perform a bladder
scan showing 800mls of urine. You report your findings to the
Registered nurse including the interventions you have already
performed.
Identify three (3) indications and the rationale for the insertion of
an indwelling urinary catheter.
Satisfactory response
Yes ☐ No ☐
Answer:
 1.……Chronic obstruction that causes hydronephrosis.
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……Rationale: Indwelling catheter decrease the back-up of urine thus reducing the
excess fluid in the kidney.
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 2.Acute urinary retention due to benign prostatic cancer, hypertrophy or blood clots.
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……Rationale: helps in voiding of the retained urine.
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 3.…Hygienic care, it improves the patient’s hygiene status thus maintaining her dignity. .
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3.4 Explain clearly the reasoning behind specific decisions and actions being taken in the context of the
health care of a person.
Question 3.4a The Doctor orders insertion of an IDC (Indwelling catheter).
You have just finishedinserting Jessica’s IDC (Indwelling
catheter) and have taped the catheter securely to her leg for
comfort and safety.

Explain three (3) specific nursing interventions including the
rationale for each, for the ongoing management of the IDC
(Indwelling catheter).
Satisfactory response
Yes ☐ No ☐
Answer:
1.…Ensuring thorough hand washing before and after caring for Jessica.
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…Rationale: applying aseptic techniques such as hand washing before performing a
procedure reduces the risk of infection. (Lo, et al., 2014).
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 2.Ensure Jessica maintains a generous and reasonable fluid intake.
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Rationale: helps in monitoring fluid intake and output with ease.
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 3.…while removing the catheter, have the patient take several deep breaths. …rationale:
this will help the patient relax while removing the catheter, thus allows for easy
removal of the Indwelling catheter.
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Teacher Comment:
A supra-pubic catheter can also be used to drain the bladder.
Question 3.4b
Provide two (2) indications for the insertion of a suprapubic
catheter and three (3) nursing interventions for managing a
supra-pubic catheter.
Satisfactory response
Yes ☐ No ☐
Answer:
 Indications:
 1.it can be chosen when it is more comfortable and less likely to give the patient an
Teacher Comment:
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infection as compared to the indwelling urethral catheter.
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 2.…suprapubic catheters can be used when there is need of urethral diversion because
of urethral trauma. (the urethral tube has been damaged).
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Management:
 1.The nurse should always wash his/her hands before with soap and clean water before
and after handling or caring for the catheter.
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 2.The nurse should ensure that the catheter is not kinked or twisted and that the urine is
flowing into the urine collecting bag. .
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 3.Urine collecting bag should be kept below the bladder level..
 ………………………………………………………………………………………………………
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Question 3.4c  Continuous Bladder Irrigation is usually indicated for male’s post
TURP (Trans urethral prostatectomy).
Provide a reason for this procedure and three (3) nursing
interventions for managing a person with a continuous bladder
irrigation.
Satisfactory response
Yes ☐ No ☐
 2…when the catheter cannot be unblocked in the first 24 hours of the procedure the
nurse should avoid attempting catheterization instead should call the urologist this is
in order to prevent the risk of prostatic capsular perforation or sub-trigonal catheter
placement on re insertion. .
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 3…Continuous bladder irrigation to minimize the risk of clot formation and over
distension of bladder.
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Teacher Comment:
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3.5 Identify areas for quality improvement including organisational processes in the care of a person with
complex skills.
Question 3.5 Identify two (2) places you may access information ensure your
knowledge and skills are current to meet the needs of a person
with complex needs.
Satisfactory response
Yes ☐ No ☐
Answer:
………………………………………………………………………………………………
1. Nursing text books.
…………………………………………………………………………………………
2.Procedure manuals.
………………………………………………………………………………………………
……………………………………………………………………………………………
Teacher Comment:
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Section E – Marking Guide Student Answer Sheet
Assessment number: 4/5 Assessment title: Workbook assessment
Student ID: Student name:
Unit code: HLTENN005 Unit title: Contribute to nursing care for a person with
complex needs
Date:
Section F – Feedback to Student
Has the student successfully completed this assessment task? Yes No
☐ ☐
This section to be completed by the teacher only.
To achieve a satisfactory result the student must :
 Answer all questions
 Must provide explanations/rationales to demonstrate a consolidated knowledge base and critical
thinking skills that demonstrate they are safe to practise in the clinical environment.
Element 1: Satisfactory / Not satisfactory
Element 2: Satisfactory / Not satisfactory
Element 3: Satisfactory / Not satisfactory
Overall : Satisfactory / Not satisfactory
Additional Assessor comments (as appropriate):
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References.
Wang, D., Li, T., Yu, J., Hu, Y., Liu, H., & Li, G. (2015). Is nasogastric or nasojejunal decompression necessary
following gastrectomy for gastric cancer? A systematic review and meta-analysis of randomised controlled
trials.
Journal of Gastrointestinal Surgery,
19(1), 195-204.
Liao, C & Qin, Y 2014, ‘Factors associated with stoma quality of life among stoma patients’,
International Journal of
Nursing Sciences, vol. 1, no. 2, pp. 196-201, viewed 26 April 2017
Nasogastric Intubation and Feeding." Gale Encyclopedia of Nursing and Allied Health. . Retrieved May 16, 2019 from
Encyclopedia.com: https://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/
nasogastric-intubation-and-feeding-0
Averch, T. D., Stoffel, J., Goldman, H. B., Griebling, T. L., Lerner, L., Newman, D. K., & Peterson, A. C. (2015). AUA
white paper on catheter associated urinary tract infections: definitions and significance in the urological
patient.
Urology practice,
2(6), 321-328
Steinhagen, E., Colwell, J., & Cannon, L. M. (2017). Intestinal stomas—postoperative stoma care and peristomal skin
complications.
Clinics in colon and rectal surgery,
30(03), 184-192.
Lo, E., Nicolle, L. E., Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., ... & Yokoe, D. S. (2014). Strategies to
prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
Infection Control & Hospital
Epidemiology,
35(5), 464-479.
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Resubmission allowed: Yes ☐ No ☐ Resubmission due date: .
Assessor name:
Assessor signature:
Date:
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