Nursing Assignment: Care Plans, Risks, and Assessments

This nursing assignment addresses a range of critical topics within the healthcare field. It begins with an exploration of cognitive deficits and the conditions that can cause them, followed by a discussion of cognitive impairment, including behavioral strategies for management. The assignment then delves into emergency procedures such as cardiopulmonary resuscitation (CPR), including the correct depth and rate of chest compressions, and the situations in which CPR should be stopped. It also covers the proper placement of AED pads and safety precautions. The document further explores between-the-flags response systems, episodic care, and risks associated with various patient populations. It also discusses anxiety and depression in older adults, general anesthesia and its risks, post-surgery care, and cognitive screening tools. Additionally, the assignment covers venous thromboembolism, deep vein thrombosis, pulmonary embolism, and factors contributing to these conditions. It also addresses the risks associated with prolonged hospital stays, mental health issues, risk assessment tools, medication non-compliance, and methods for monitoring nutritional and hydration status.

Running head: NURSING ASSIGNMENT
NURSING ASSIGNMENT
Name of Student:
Name of University:
Author’s Note:

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Answer 21:
According to Healthdirect.Gov (2019), Cognitive deficit is described as the mental
condition of the individual that is they are not able to concentrate or pay proper attention to
anything and along with also feeling complications in the understanding and the speaking.
Five condition that might cause cognitive deficit include,
1. Excessive substance use
2. Physical injury
3. Infections which include pneumonia and the urinary tract infection
4. Deficiency of vitamin
5. Reaction to any medication
Answer 22:
Cognitive impairment is referred to as the problem associated with thinking and memory
difficulties (Health.Vic.Gov.Au, 2019). The most frequent type of the cognitive impairment
includes, dementia, delirium and depression. In the hospital setting, around 30% of the total
older population have been suffering from cognitive impairment and has greater risk of other
complications such as, medication issue, falls. Hence, to maintain the cognitive impairment,
behavioural strategies can be applied which incudes, (Health.qld.gov.au. 2019),
1. Summarising the meaning of the sentences
2. Predicting meaning from the context.
3. Repeating the words for better understanding of the patient.

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Answer 23:
The individual suffering from cardiac arrest should be provided with cardiopulmonary
resuscitation. The recommended depth of the compression in the adult who has been suffering
from the cardiac issue is to provide chest compression at the rate of 100-120/min and the depth
should be minimum of 2 inches that is 5 cm. If excess chest compression have been provided, it
might hamper the health (Idris et al., 2015). It is done to search the pulse of the person having
the cardiac arrest and is done to rescue the patient.
Answer 24:
The head tilt or the upper chin lift is the procedure used to prevent the obstruction of the
airway or to open the passage to the airway. In the case of the unconscious patient, it can be one
of the most simplest and considerable way to open the airway to make them conscious. In the
head tilt or the upper chin lift, the tongue is prevented to obstruct the airway. It is done in the
conscious patient by tilting the head towards back, which is done by applying the pressure to the
chin and the forehead (Jo et al., 2019). After opening of the airways, the patient comes to the
conscious state.
Answer 25:
Cardiopulmonary resuscitation is the procedure that is used to return the patient into the
conscious state by searching for the pulse rate. Cardiopulmonary resuscitation if once started
should not stop In the middle (Cook & Thomas, 2017). The condition when the
Cardiopulmonary resuscitation is stopped includes,
1. When the signs of life which includes breathing has been observed.
2. When the person performing the CPR gets fatigued.

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3. In the case, when the patient is identified to be suffering from any life-threatening
disease.
Answer 26:
Chest compression if once started should not be interrupted in the middle, however it is
seen that there are times when the person providing the CPR gets fatigues, there are chances that
he or she might leave providing CPR (Safarzynska, 2017). If it is discontinued, it might lead to
death and hence in order to prevent that, there are certain recommendations which include, that
if there are more one rescuer present, CPR can be provided by transferring the rescuers. To
prevent fatigue during the CPR, the another person should take oven in every one to two minutes
and during these minimum delay should be ensured.
Answer 27:
AED pad placement is the procedure that is used to deliver shock to the heart of the
patient in order to bring it back to the normal rhythm. The AED pad is placed on the chest of the
patient. before applying the pad the skin of the chest of the patient is prepared (Foster & Deakin,
2019). If the chest of the patient is hairy, hair should be removed and before applying the shock,
the skin of the patient is dried as water is the good conductor of the electricity and hence will
reduce the impact of the shock.
Answer 28:
To ensure safety during the AED pad placement there are certain do’s and do not’s which
includes (Kumar, 2018),
1. Open the shirt of the patient and wiping the bare chest to ensure the skin is dry,

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2. No one should touch the patient after the Pads are attached and also when the
person has been given shock.
3. The AED should not be used near water.
Answer 29:
Between the Flags response system is the system designed by the Clinical Excellence
Commission by collaborating it with the clinicals, managers. It is safety net for the patient of the
NSW health care facilities. The primary principle of the Between the Flags response system is to
protect the well-being of the patient from the unnoticed deterioration. Other principle is to ensure
that they are getting proper care (Cec.health.nsw.gov.au, 2019).
Answer 30:
Episodic care is referred to as the single encounter or meeting with the patient in order to
focus on the concern of the patient and ongoing care is not expected (Pines et al., 2016)..
The risk which are associated with episodic care in paediatric patient includes,
1. Nutritional status
2. Age
3. Cognitive status
The risk which are associated with episodic care in older patient includes,
1. Immobility
2. Presence of the morbidity
3. Mental illness

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Answer 31:
Anxiety and depression among the older adults is very frequent in the healthcare setting.
The nurse taking care of the patient should have the knowledge regarding the factors that are
responsible for the causing depression and anxiety (Weiss et al., 2015). The factor which
contributes to the development of anxiety and depression includes:
1. Medications side effect
2. Health care environment
3. Significant change in the living environment
Answer 32:
General anaesthesia when provided helps to bring back the reversible loss of analgesia
and the consciousness which help the surgeon to treat the patient (Powell et al., 2016). However,
it is observed that with the prolong use of the anaesthesia there are certain risks which include,
1. Chances of getting obstructive sleep apnoea
2. Seizures
3. High blood pressure
Answer 33:
General anaesthesia is defined as the clinically induced coma, but some consider as the
sleep which is not true. It is usually administered before the surgery to make the patient
unconscious. With the use of the general anaesthesia, there are certain complication associated
which include (Simonsen et al., 2018),
1. Memory loss and the temporary confusion
2. Difficulty during urination

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3. Vomiting and nausea
4. Feeling cold and shivering
5. Due to the breathing tube, sore throat occurs
Answer 34:
Post-surgery care is very important as it helps in healing the wound of the patient. The
post-operative care depends upon the type of surgery patient had underwent. It includes wound
care and the pain management (Ran et al., 2016). There are certain signs and symptom for the
deteriorating patient in the post-operative care which includes,
1. Delayed and slow capillary refill
2. Abnormal edema and swelling
3. Chest pain
Answer 35:
Cognitive screening is one of the cognitive impairment screening tool which is used by
the general practitioner in order to provide primary care to the patient (Malmstrom et al., 2015).
This screening tool is used to screen several types of the cognitive impairment such as dementia.
During the screening of the patient there are certain consideration which should be taken into
account by the nurses and the health care staff in the clinical setting which includes,
1. The nurse should ask the patient in order to perform a series of the different tasks which
help to asses one or more than one domains of the cognitive such as, attention, memory
and language.
2. The nursing should focus more on the screening and the treatment of the patients.

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Answer 36:
Venous thromboembolism is demarcated as the clotting of the blood which starts in the
vein. It is among one of the vascular diagnosis and ranks third after the heart attack and the
stroke, affecting demographic population (Heit, Spencer & White, 2016). It is of two types, one
is vein thrombosis and the other is pulmonary embolism. vein thrombosis occurs when the blood
clotting forms a deep vein in the leg and pulmonary embolism is said to be occur when the clot
breaks and travel to the lungs from the leg.
Answer 37:
Deep vein thrombosis is when the clotting of the blood forms one or more than one deep vein
in the level (Di Nisio, van Es & Büller, 2016). The symptoms which aids to identify the deep
vein thrombosis includes:
1. Swelling in the leg or in the affected part
2. Pain in the leg along with Cramping and soreness in the leg
3. Warmth feeling in the leg
4. Discoloration or red colour of the skin
Answer 38:
There are many factors that enhances the risk of getting deep vein thrombosis in to the
body. If these risk factor are known, the deep vein thrombosis can be prevented (Watson,
Broderick & Armon, 2016). The potential complication or the risk that has been associated with
deep vein thrombosis includes,
1. Prolonged bed rest usually in case of patient recommended to take bed rest

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2. Obesity an overweight as it increases the pressure in the veins of the legs and the pelvis.
Answer no 39.
The two symptoms to identify the pulmonary embolism are as follow:
 Shortness of breath or rapid breathing is the major prevailing symptoms (Fernández et al.
2015)
 Pain in chest which goes on extending to the arms, neck and jaw.
Answer no 40.
The two major complication of the person who is immobile is as follow:
 Musculoskeletal complications- The strength and endurance of muscle will be lost (Li et
al. 2018).
 May cause breakdown of skin
Answer no 41.
Three risk that is linked with the increase length of hospital stay are:
1. Patient may get hospital acquired infection from the neighbour patients due to long stay.
2. It may harm the patient mentally and can lead to health deterioration (McEwan et al.
2015).
3. Situation arise of disrupt flow of patient and shortage of bed due to which access to care
is hurdled (Bouras et al. 2015).
Answer no 42.

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The risk that a client with mental health issue may pose on the other can be related to
physical harm. They can attack on other people with any deadly things (Hoeft et al. 2018). They
are not their state of mind to act wisely, their behaviour and attitude can hurt the person caring. It
is hard to manage the mentally ill patient and they become psychological burden for other. Their
aggressive attitude can create a situation of verbal miscommunication which can hurt other
emotionally (Slemon, Jenkins and Bungay 2017).
Answer no 43.
Two risk assessment tools that may be used to assess the risk associated with mental health
issues are:
1. Sainsbury risk assessment tool (Dalziel et al. 2017).
2. FACE risk profile tool (Ikävalko et al. 2015).
Answer no 44.
In medicine, non-compliance is related to failure or rejection to comply. It can be define
as refusal by the patient in taking prescribed medicine and following a given treatment plan
(Spence, 2018). It is often seen that patient who continuous to take medicine and once they starts
to feels better, people stops to continue it. Such behaviour is regarded as non-compliance.
An example of risk from non-compliance with medication or treatment is slower recovery
from disease and emergence of past illness (Shah et al. 2015).
Answer no 45.
Three methods used to monitor the nutritional and hydration status and linked risk of person
are:

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1. Assessing the sign and symptom of the patient for low appetite, fatigue, dizziness and
frequency of urination. It can develop risk of delirium (Ersoy, Ersoy and Kutlu 2016).
2. Measuring haematological parameters for example fluid volume, blood pressure and
sodium concentration. Change in blood volume or low sodium can pose a risk of diabetes
and nausea (Berry et al. 2016).
3. Measuring the weight/BMI as it is linked sign of vitamin and other essential nutrient
deficiency (Bertoni et al. 2017).
Answer no 46.
Four circumstance when there the need to perform pain assessment for a person are:
1. When person shows non-verbal sign of discomfort (Strand et al. 2019).
2. When person is not able to move or change its position.
3. When the person is having difficulty in taking breath or decrease in oxygen saturation or
there is high heart rate (Tournebize et al. 2016).
4. When person has fallen or met any physical injury.
Answer no 47.
Comorbidity is the situation when there is occurrence of more than one disorder in a
person. The issue can arise at the same time or it can come one after the other, it tends to worsen
the health condition of the patient (Tiira, Sulkama and Lohi 2016).
The potential impact on planning nursing care for comorbidities are difficulties in
focusing on the symptom. Nurse are not able to build a proper care plan as the patient show sign

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and symptoms of more than one disease (Fernando et al. 2017). Planning treatment for one
disease can be contradicting to other disease.
Answer no 48.
Three strategies to maintain a safe environment for oneself and patient in the health
environment are as follows:
1. Actively practicing hand hygiene before and after assessing the patient.
2. To construct a safety health management plan where guideline is communicated to every
health care staffs and health department and excluded potential hazards (Ammouri et al.
2015).
3. Development healthy practice of care by educating the staffs and patient and family
about the safe health care environment (Stevenson et al. 2015).
Answer no 49.
The three steps of the falls risk assessment tool (FRAT) are as follows:
1. To check the risk status of falls.
2. To make a risk factor checklist of the falls which include many questions related to falls
(Chang et al. 2019).
3. Third step is to make an action plan for the eliminating the problem or issue related to
falls.
Answer no 50.
Five interventions to prevent falls in a clinical setting are: