HLT54115 Diploma of Nursing: Complex Needs Written Assessment

This document is a comprehensive written assessment for the HLT54115 Diploma of Nursing, focusing on contributing to the nursing care of a person with complex needs. The assessment covers a wide range of topics, including the importance of nursing theory, chronic diseases, pathophysiology, professional standards for enrolled nurses, and the differences between stable and unstable angina. It also addresses the signs and symptoms of a CVA, and includes case studies involving patients with metastatic prostate cancer, diabetes and COPD, and a patient with a CVA. The assessment requires detailed nursing assessments, outlining referrals, and interventions related to immobilization, vital signs, oxygen therapy, and hyperglycaemia. Furthermore, the assessment includes questions on the Code Blue process, indwelling catheters, and nasogastric tubes, emphasizing nursing management and patient well-being. The assignment demonstrates the application of nursing knowledge in various clinical scenarios, reflecting a holistic approach to patient care.

HLT54115 Diploma of Nursing
HLTENN005 Contribute to nursing care of a person with complex needs
Written Assessment Student Copy
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Instructions to Students
Welcome to the written assessment. To successfully complete the assessment
requirements, you need to follow the following instructions.
Step 1
Read the study guide and the related resources.
Step 2
Read this assessment to gain an understanding of what you need to do to complete the unit.
Talk to your trainer or supervisor and ask for help if you need to.
Step 3
Complete all questions in this assessment. Please write clearly in pen (not pencil). You
may attach printed answers if you prefer. Do not remove any pages from this assessment.
Step 4
Complete the cover sheet and attach to this assessment. We recommend you make and
keep a copy of the entire Assessment.
Step 5
Submit for assessment.
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Question 1
The following website may assist with this question
http://currentnursing.com/nursing_theory/application_nursing_theories.html
Discuss the importance of nursing theory to practice.
Answer:
The case of the client suffering from a mental health issues has been taken as they require
attention and proper care from a registered healthcare practitioner such as enrolled nurses
who specialize in mental health issues and has required skills and qualifications. As an
Enrolled Nurse, the responsibilities should be as follows-
1. The mental health nurse values different cultures and their beliefs by ensuring his/her
practice is not discriminating anybody. He/she should be accountable for their actions
(Mental Health Nurses in Australia, 2013).
2. He/she should provide satisfaction to people with mental health issues and involve in
the process of their recovery.
3. He/she should follow the standards of treating a mental health patient.
Question 2
The following website may assist with this question
http://www.aihw.gov.au/chronic-diseases/
What is meant by the term chronic disease?
Answer:
The client was suffering from depression and anxiety issues from a brief period of time.
People suffering from depression and anxiety issues should be taken care with utmost care
by creating a therapeutic relationship with the enrolled nurses (National Mental Health
Strategy, 2013). Enrolled nurses should establish trust, respect their beliefs and be
empathetic towards their condition. This helps the people with mental illness to recover
soon. In order to understand one’s own condition of mental health is very important. Family
and close people should also understand the need for care of people having mental health
issues. In order to understand a patient’s mental condition, nursing home risk assessment
tool can be used.
Question 3
The following website may assist with this question
http://medical-dictionary.thefreedictionary.com/pathophysiology
Define the term pathophysiology.
Answer:
The client suffered depression and anxiety issues and with the help of biopsychosocial
model, he received relevant treatment and care (Cardoso, 2013). His condition was
examined understanding the psychological, biological and social factors that contributed to
his depression. His depression developed due to impaired emotional balance and physical
disorders. Nevertheless, the patient received the required care by understanding his
condition first. An accurate diagnosis was done which included the patient’s physical
examination, asking them about their feelings, cross-checking their medical history and
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laboratory tests. The patient was provided with psychotherapy treatments and attended few
sessions of face-to-face interview to know their current mental condition.
Question 4
The following website may assist with this question
http://www.nursingmidwiferyboard.gov.au/
As an enrolled nurse must adhere to organisational policies and procedures. Discuss other
professional standards that the enrolled nurse must adhere to.
Answer:
There are numerous researches made focusing on pathophysiology of depression, yet not
much concrete results have been achieved (Fekadu, Shibeshi and Engidawork, 2016).
Although there has been a slow development in finding the exact treatment and drugs for
depression, but there are lack of understanding for this condition too. The client showed
chronic stress due to external factors affecting his mental and physical condition. Amygdala
is one of the brain’s area which got affected in case of the patient suffering from depression.
Amygdala controls the emotional activity of the brain which was affected in the behaviour of
the patient (Cullen, et.al., 2014).
Question 5
The following website may assist with this question
http://www.myvmc.com/diseases/angina-pectoris-and-unstable-angina/
Discuss the differences between stable and unstable angina?
Answer:
The people having symptoms of depression tend to have a low self-esteem and confidence
as compared to people with normal mental condition. This impacts their relationship with
their known people and even with themselves. Depression ultimately leads to isolation and
the chances of suicidal thoughts increases. As a part of the patient’s symptoms, depression
affected his physical health to a significant level. The patient didn’t have a healthy lifestyle
which resulted in onset of a slower heart rate. His immune system was disrupted as he was
sinking both mentally and physically. The patient required a long-term treatment to overcome
the symptoms.
Question 6
What are some signs and symptoms a patient will exhibit if suffering a CVA?
Answer:
Nurses are registered practitioners appointed by designated nursing homes who pay
attention to the symptoms of the issues faced by the patients and constantly work for their
well-being. They provide psychological care to the patients by understanding their mental
health conditions. The first part of the treatment was to provide medical assistance to the
patient due to his loss in appetite and stunted growth. He was given prescribed anti-
depressants that helped him to get proper sleep and rest. The next step was to informally
engage the patient to talk about the reason behind his depression, and find out whether it is
a situational depression or prolonged one. The last step was to keep him motivated and ask
out for help at any time.
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Question 7
The following website may assist with this question
http://heartfoundation.org.au/about-us/what-we-do/heart-disease-in-australia
Mr. Alan Andrews, aged 78 years presented to the emergency with new-onset low back
pain. The client has a history of metastatic prostate cancer, which was diagnosed two years
ago, and a solitary asymptomatic bone metastasis in the right pubic bone. To date, he had
been managed with androgen deprivation therapy (goserelin) alone. His performance status
was good and his prostate-specific antigen (PSA) level stable. His past medical history
included hyperlipidaemia and atrial fibrillation. Mr. Andrews is on atorvastatin and warfarin.
He had no known allergies, was a non-smoker and did not drink alcohol. Mr. Andrews lives
by himself and his family lives interstate, he states that he has needed assistance to attend
to the cleaning of his house.
Part A
Outline what you will include in the nursing assessment on admission.
Answer:
Mr. Alan Andrews is a 78 years old man suffering from a low-back pain. The patient was
brought to the emergency and the nursing assessment would comprise a process of
gathering relevant information of his physical and mental condition. The assessment will
start with understanding the root cause of his low back pain.
Part B
Outline one referral you will make, and why you would make that referral, to ensure Mr
Andrews receives the necessary assistance on discharge.
Answer:
Mr. Andrews required to undergo an immediate MRI Scan and an X-Ray scan of his spine. A
Chiropractor can be suggested to provide him relief from the lower back pain.
Part C
Mr Andrews states that he has difficulty mobilising due to pain. He refuses to mobilise.
Discuss the effects of immobilisation and your nursing interventions.
Answer:
Mr. Andrews is facing difficulty in moving with the pain but this would make his vulnerable to
many other problems related to spine.
Question 8
Mrs Joan Walker is a 60-year-old woman with a three year history of diabetes is seen for
worsening dyspnea and cough. She has had chronic obstructive pulmonary disease (COPD)
since age 55. She now has dyspnea with walking one-third of a block and a persistent
cough. Her type 2 diabetes has been managed with diet.
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Mrs Walker is anxious, her blood pressure 130/70 mmHg, pulse 120, respiratory rate 28,
BSL 19.3, O2Sats 89 and weight 106kg. Mrs Walker states that she is having difficulty
mobilising and has had difficulty adhering to her diabetic diet. Lungs are clear to percussion,
but wheezing is present bilaterally. No accessory muscles are being used. No cyanosis is
present.
Part A
What observations will you report to the RN?
Answer:
The observations would be increase in blood pressure due to anxiety and worsening cough
and dyspnea. Along with that, Mrs. Joan Walker also suffered from Diabetes and chronic
heart disease.
Part B
The enrolled nurse provides nursing care working under the direction and supervision of the
registered nurse. What nursing interventions and monitoring may be required for Mrs
Walker?
Answer:
Mrs. Walker suffers from dyspnea which made her anxious and difficult to breathe and
mobilize. As an enrolled nurse, it was important to provide medications, controlled oxygen
therapy and relaxation techniques.
Part C
Discuss the normal ranges for vital signs.
Answer:
The Sixth vital sign is considered as the Dyspnea pain which makes the patient experience
breathlessness.
Part D
Discuss the referrals that Mrs Walker requires.
Answer:
The referral was made for a Pulmonologist.
Part E
Mrs Walker is ordered incentive spirometry. Discuss the reasons for using incentive
spirometry.
Answer:
Incentive Spirometry was used to keep the lungs healthy even after a surgery or from a lung
illness.
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Part F
Mrs. Walker is ordered oxygen therapy. Discuss the risk.
Answer:
The risk from oxygen therapy can be a bloody nose, morning headaches and skin irritation.
Part G
Mrs Walker has hyperglycaemia. Discuss the short-term symptoms of hyperglycaemia.
Answer:
The short-term symptoms of hyperglycaemia are dehydration, weight loss, and frequent
urination.
Part H
Mrs. Walker has been ordered actrapid. Mrs. Walker has rung the buzzer and states that
she feels unwell, you note that she feels cold and clammy and seems confused. You
discover that there has been a medication error and she has received 3 times what she was
ordered. Discuss your actions
Answer:
The immediate action was to provide her with actrapid which is an insulin given for diabetes.
Question 9
Enrolled nurses need to be competent in providing Basic Life Support in order to respond to
Code Blue Emergencies. Discuss the Code Blue process for a facility where you have
attended clinical placement.
Answer:
The Code Blue process starts with the First Respondent who calls for help and starts
compression. The Second Respondent brings in the emergency equipment required. The
third respondent will turn the defibrillator on to gain the pulse. Fourth and fifth respondents
will check the IV fluids and documentation process respectively.
Question 10
Mr Greg Hall, 89, has had a CVA 2/12. He lives at home with his wife who is his carer. Mr
Hall has had a fall at home and has been admitted to the medical ward. On admission his
wife states that he has not passed urine for 2 days and has been very confused. He is
ordered a indwelling catheter after a bladder scan.
Part A
Discuss the indications for an indwelling catheter
Answer:
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The Code Blue process starts with the First Respondent who calls for help and starts
compression. The Second Respondent brings in the emergency equipment required. The
third respondent will turn the defibrillator on to gain the pulse. Fourth and fifth respondents
will check the IV fluids and documentation process respectively.
Part B
List the equipment required.
Answer:
The device required is an Indwelling catheter tube or Foley Catheter.
Part C
Discuss special precautions after insertion.
Answer:
The tube should be checked so that it doesn’t slip away. The patient should not take proper
bathes. The urine bag should be drained on time.
Part D
Discuss the ongoing nursing management.
Answer:
The ongoing nursing management checks for blood clots in the urine, pain around the belly
and any swelling and inflammation due to catheter.
Part E
Due to inadequate oral intake, Mr Hall is ordered a nasogastric tube. Discuss nursing
interventions that consider Mr Hall’s well-being.
Answer:
Nasogastric tube feeds the patient but they require proper care and safety. The
complications should be known and tube position should be properly done.
Part F
Mr Hall is extremely anxious after having his nasogastric tube inserted. Mr Hall states that
he is reluctant to attend to his hygiene as he is concerned that the nasogastric tube may “fall
out”. How could you provide reassurance and support to Mr Hall so that he can attend to his
hygiene needs?
Answer:
The tube should be taped and hygiene is maintained by the nurses.
Part G
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Mr Hall has been ordered temazapam to treat his insomnia symptoms. What potential side
effects should you be aware of? If Mr Hall has an adverse effect from the medication, what
would your actions be?
Answer:
Temazepam can make the patient dizzy and feel nauseatic. As the patient has the
nasogastric tube, the dosage will be lessened to reduce the side effects.
Question 11
Improving care for individuals with chronic illnesses is perhaps the greatest challenge facing
the Australian health care system. Traditional chronic disease management that focuses on
single conditions such as diabetes, coronary artery disease or depression does not meet the
needs of clients with multiple morbidities. Clients with multiple morbidities typically seek care
from a variety of specialities. Discuss the approach to chronic health management that has
had the best client outcomes.
Answer:
Chronic Health Management can be done by coordinating the care planning for patients. The
use of multidisciplinary team approach can help. It is necessary to ensure the efficiency of
team members at all situations and by providing services beyond working hours for
emergency cases.
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Reference List
Beyond Blue, 2018. A Guide to What Works for Depression. [pdf] Available at:
<http://resources.beyondblue.org.au/prism/file?token=BL/0556>
Cardoso, J., 2013. The Biopsychosocial Perspective to Mental Health and Illness. [online]
Available at: <https://www.socialworkhelper.com/2013/07/16/the-biopsychosocial-
perspective-to-mental-health-and-illness/>
Cullen, K.R., Westlund, M.K., Klimes-Dougan, B., Mueller, B.A., Houri, A., Eberly, L.E. and
Lim, K.O., 2014. Abnormal amygdala resting-state functional connectivity in adolescent
depression. JAMA psychiatry, 71(10), pp.1138-1147.
Fekadu, N., Shibeshi, W. and Engidawork, E., 2016. Major depressive disorder:
pathophysiology and clinical management. J Depress Anxiety, 6(255), pp.2167-1044.
Gray, J., Afzali, H.H.A., Beilby, J., Holton, C., Banham, D. and Karnon, J., 2014. Practice
nurse involvement in primary care depression management: an observational cost-
effectiveness analysis. BMC family practice, 15(1), p.10.
Mental Health Nurses in Australia, 2013. Scope of Practice 2013 & Standards of Practice
2010. [pdf] Available at:
<https://researchoutput.csu.edu.au/ws/portalfiles/portal/21102912/9394240_Published_repor
t_OA.pdf>
National Mental Health Strategy, 2013. National Practice for Standards for the Health
Workforce 2013. [pdf] Available at:
<https://www.health.gov.au/internet/main/publishing.nsf/content/5D7909E82304E6D2CA257
C430004E877/$File/wkstd13.pdf>
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