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CONTRIBUTE TO CLIENT ASSESSMENT AND DEVELOPING NURSING CARE PLANS
HLTEN503B
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Please leave blank
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CONTENTS
LEARNING RESOURCE BOOKLET.................................................................................4
HUMAN GROWTH, DEVELOPMENT & FUNCTIONAL NEEDS.............................................6
Activity 1: Growth and development...........................................................................................6
Activity 2: Growth and development scenarios.........................................................................15
NURSING PROCESS & CLIENT ASSESSMENT (SYSTEM APPROACH)..............................22
Activity 1: Collection information..............................................................................................22
Activity 2: Identification of correct diagnoses............................................................................24
Activity 3: Nursing care plans....................................................................................................28
Activity 4: Data collection admission note – Part 1....................................................................32
TAKING CLIENT, HISTORIES, PHYSICAL ASSESSMENT – VITAL SIGNS...........................34
Activity 1: Data collection vital signs admission note – Part 2...................................................34
Activity 2: Vital signs quiz.........................................................................................................36
Activity 3: Data collection - skin integrity assessment..............................................................40
URINALYSIS, SPECIMEN COLLECTION & PAIN ASSESSMENT........................................44
Activity 1: Urinalysis and specimen collection...........................................................................44
Activity 2: Pain assessment.......................................................................................................46
NEUROLOGICAL & NEUROVASCULAR OBSERVATIONS & BGL.......................................52
Activity 1: Specific observation.................................................................................................52
Activity 2: Neurological observations (Lab practice)..................................................................56
ADMISSION & DISCHARGE PLANNING.......................................................................60
Activity 1: Admissions with different age groups.......................................................................60
Activity 2: Nursing care plans and development stages............................................................62
CLIENT ASSESSMENT SKILLS....................................................................................69
Activity 1: LAB case scenarios...................................................................................................69
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LEARNING RESOURCE BOOKLET
STUDENT BOOKLET
Course Code Course Title
HLTEN503B Contribute to client assessment and developing nursing care plans
Check list
Section Activity Title Activity Number
Session 1
Human growth, development & functional needs
Growth and development 1
Growth and development scenarios 2
Session 2
Nursing process & client assessment (system approach)
Collect information 1
Identification of correct diagnoses 2
Nursing care plans 3
Data collection admission note – Part 1 4
Session 3
Taking client, histories, physical assessment – vital signs
Data collection vital signs admission note – Part 2 1
Vital signs quiz 2
Data collection (skin integrity assessment) 3
Session 4
Urinalysis, specimen collection & pain management
Urinalysis and specimen collection 1
Pain assessment 2
Session 5 & 6
Neurological & Neurovascular observation
Specific observation 1
Neurological observations (lab session) 2
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Session 7
Admission & Discharge planning
Admissions with different age groups 1
Nursing care plans and development stages 2
Session 8
Client assessment skills
LAB case scenarios 1
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HUMAN GROWTH, DEVELOPMENT & FUNCTIONAL NEEDS
Activity 1: Growth and development
STUDENT INSTRUCTIONS
The following activity requires students to:
1. Select one (1) of the following developmental age groups:
Infant to late childhood Adolescence Younger adulthood Older adulthood
2. Work in pairs to research your chosen developmental age group
3. Answer the questions provided for your chosen developmental age group below
HINT TIP
The following activity will provide you with the necessary knowledge required to answer Activity 2: Growth and development scenarios and prepare you for your exam.
READINGS
Students are required to refer to the following textbooks:
Hendry C et al (2012) Development, growth and repair from conception to old age. Nursing Standard, vol. 26, no. 50, pp. 44-49.
Tabbner’s 6th Edn, 2013 Theories of growth and development: Chapter 10, 11, 12 & 13.
INTERACTIVE ZONE
Let’s get interactive!
Find articles on EBSCO host or read textbooks to answer the questions below.
EBSCO host Online Research Database
www.ebscohost.com
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What are the cognitive development/changes in infant to late childhood?
____________________________________________________________________________________________
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What are the physical development/changes in infant to late childhood?
____________________________________________________________________________________________
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What are the psychosocial development/changes in infant to late childhood?
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What are the common health risks/problems in infant to late childhood?
____________________________________________________________________________________________
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What are the common health promotion/needs in infant to late childhood?
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What factors influence growth and development in infant to late childhood?
____________________________________________________________________________________________
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List any specific developments or changes seen during infant to late childhood.
____________________________________________________________________________________________
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Infancy is the stage of development from birth to 12 months. There are multiple areas of growth and development that occur throughout infancy and early childhood (Tabbner’s 2013).
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INFANT TO LATE childhood
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What are the common health risks/problems in adolescence?
____________________________________________________________________________________________
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List any specific developments or changes seen during adolescence.
____________________________________________________________________________________________
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What factors influence growth and development in adolescence?
____________________________________________________________________________________________
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What are the common health promotion/needs in adolescence?
____________________________________________________________________________________________
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ADOLEscence
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Adolescence is the period of development from age 12 to 20 and is the stage that marks the transition from childhood to adulthood (Tabbner’s 2013).
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2
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What are the common health promotion/needs in adolescence?
____________________________________________________________________________________________
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Younger adulthood is a period of development from 19-20 years, is the period when a person transitions to maturity, independence and considerable social change (Tabbner’s 2013).
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YOUNGER adulthood
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2
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Old age consists of ages nearing or surpassing the life expectancy of human beings, and thus the end of the human life cycle (Tabbner’s 2013).
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OLDER adulthood
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____________________________________________________________________________________________
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Activity 2: Growth and development scenarios
STUDENT INSTRUCTIONS
Let’s put theory into practice!
Students are required to read the case studies below and answer the questions provided.
HINT TIP
The following exercise will provide you with the necessary knowledge required to prepare you for your upcoming exam.
Scenario one (1): Infant
Nina is a twenty-two (22) year old and has attended the maternal-child health clinic with her eight (8) week old baby for a routine check-up. Nina is curious about the stages of infant development and asks, ‘How is my baby doing? How long should she be and how much should she weigh now? When will she start smiling and trying to roll onto her back? Is there anything that I need to be careful of when I look after my little girl?’
1. What subjective and objective data do you need to collect before you answer Nina?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_______________________________________________________________________________________
2. What would you tell Nina in response to all of her questions?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
________________________________________________
Scenario two (2): Children
Anna, a three (3) year old girl, is admitted to your ward following a fall sustained in the home. She weighs 35kg and you notice on admission that there is a bruise on her back, she is very pale and does not attempt to communicate, either verbally or physically with you. You ask her mother if she is normally very quiet and she tells you
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‘she never speaks, she just sits and watches television all day’. ‘I sometime get frustrated because she does not respond until I shout out to her’.
3. What physical and psychological factors may be affecting Anna’s growth and development?
___________________________________________________________________________________________________
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4. What health risks or problems are evident with Anna’s case?
___________________________________________________________________________________________________
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5. Complete the table below
List three (3) actual problems with Anna
List the nursing intervention(s) that can be utilised to improving/solving the problems?
What are the expected outcomes?
Problem 1
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Problem 2
Problem 3
Scenario three (3): Adolescence
You are employed in a clinic. As you were walking out of the treatment room, you noticed that a rather untidy looking girl, of about fifteen (15) years of age, has walked into the reception area. You approached her to find out what she required and she tearfully started to explain to you that she thinks that she may be pregnant. She does not know when her last period was and is not really clear when she had sexual intercourse.
6. What subjective and objective data do you need to collect?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
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________________________________________________
7. What support and education will you be able to provide to the girl?
___________________________________________________________________________________________________
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________________________________________________
8. List three (3) actual problems, two (2) potential problems, nursing interventions linked to each problem and what are expected outcome after each intervention.
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List three (3) actual problems List the nursing intervention linked to each problem
What are the expected outcome(s)?
List two (2) potential problems List the nursing intervention linked to each problem
What are the expected outcome(s)?
Scenario four (4): Younger adults
Steven is a thirty-eight (38) year old bus driver and has been admitted to the ward with chest pain. He states he has been experiencing pains for a week and on the advice of his wife, he decided he would see his GP. Steven is overweight and admits not exercising as much as he did when he was younger. He has not had any health screening lately and feels he has not experienced any general health issues associated with being overweight. Steven smokes half a packet of cigarettes a day, but does not drink alcohol. On admission he states, ‘I was under a lot of pressure with my company making a few redundancies in the last three (3) months. Thankfully, my wife and three (3) kids has been very supportive’.
9. What subjective and objective data do you need to collect?
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___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_______________________________________________
10.What support and education will you be able to provide to Steven?
___________________________________________________________________________________________________
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________________________________________________
11.List three (3) actual problems, two (2) potential problems, nursing interventions linked to each problem and what are expected outcome after each intervention.
List three (3) actual problems List the nursing intervention linked to each problem
What are the expected outcome(s)?
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List two (2) potential problems List the nursing intervention linked to each problem
What are the expected outcome(s)?
Scenario five (5): Older adulthood
Joseph is 72 male who was admitted to hospital, following a fall at home. He has a haematoma on his arm and on his face but has not sustained any major injuries. It is day three (3) of his hospitalisation, and you noticed that he is not his usual self today. When you inform him he has a visitor waiting to see him, he says he does not want to move and wants to stay in his bed today.
12.What issues do you think may have led to Joseph falling at home?
___________________________________________________________________________________________________
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13.What could be the reason for Joseph’s response about having no visitors?
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___________________________________________________________________________________________________
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14.What aspect of care will you consider in planning his discharge?
___________________________________________________________________________________________________
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___________________________________________________________________________________________________
__________________
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NURSING PROCESS & CLIENT ASSESSMENT (SYSTEM APPROACH)
Activity 1: Collection information
STUDENT INSTRUCTIONS
Students are required to read the Clinical scenario Box 15.1: the assessment phase and then divide the relevant information collected from the scenario into categories.
The categories are as follows:
Medical history Nursing history Subjective data Objective data Medical diagnosis Nursing diagnosis (actual or potential)
READINGS
Students are required to refer to the following textbooks:
Clinical scenario Box 15.1: the assessment phase on page 263 of the Tabbner’s 6th Edn, (2013).
Medical history
Nursing history
Subjective data
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Objective data
Medical diagnosis
Nursing diagnosis
(actual or potential)
Activity 2: Identification of correct diagnoses
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STUDENT INSTRUCTIONS
Students are required to read the scenario’s below and identify the medical and nursing diagnosis for each of the following clients.
READINGS
Students are required to refer to the following textbooks:
Clinical scenario Box 15.1: the assessment phase on page 263 of the Tabbner’s 6th Edn, (2013).
Client one (1)
Frank, 67yo, complains of ‘stubborn, old muscles’. He has difficulty walking, evidenced by his shuffling gait. During the nursing history, Frank speaks in a monotone and seems very depressed. When the EN assesses the general appearance of Frank, they notice a pill-rolling tremor. Lab tests reveal a decreased dopamine level.
(See YouTube link: https://www.youtube.com/watch?v=0-t4RTQ0EsM).
1. Identify the medical and nursing diagnosis for Frank.
Medical diagnosis
Nursing diagnosis
(actual or potential)
Client two (2)
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For five (5) days, Judy, 26yo, has had sporadic abdominal cramps of increasing intensity. Most recently, the pain has been accompanied by vomiting and a slight fever. She is bracing her R) iliac fossa and has her knees drawn up.
2. Identify the medical and nursing diagnosis for Judy.
Medical diagnosis
Nursing diagnosis
(actual or potential)
Client three (3)
During an extensive bout with Respiratory Tract Infection’s (RTI’s) Tom, seven (7), complains of throbbing ear pain. Tom’s mother notes his hearing difficulty and Tom is scared that he can’t hear properly. His tympanic membrane is red and bulging. Tom is holding his ear and crying.
3. Identify the medical and nursing diagnosis for Tom.
Medical diagnosis
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Nursing diagnosis
(actual or potential)
Client four (4)
Raman is a 46 year old man, with two (2) grown-up children and four (4) grandchildren. He has an elderly mother to look after and he has recently been diagnosed with hypertension. He also has a long-term history of asthma. He is very concerned with his new diagnosis and frustratingly stated “I will not be able to look after my mother if I am unwell like this!”
4. Identify the medical and nursing diagnosis for Raman.
Medical diagnosis
Nursing diagnosis
(actual or potential)
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Client five (5)
Peter, a 70yo male, has a long term history of right sided heart failure. He came to visit his GP with increased shortness of breath when performing his ADLs. He lives alone with no support network, in a flat which is located on level two (2) of his building that has no elevator. He appears untidy and states “I get really out of breath while I am in the shower, so I tend to avoid having one”.
Medical diagnosis
Nursing diagnosis
(actual or potential)
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Activity 3: Nursing care plans
PART 1
STUDENT INSTRUCTIONS
Students are required to read the scenario below and develop a nursing care plan for Kevin.
The nursing care plan requires you to consider the following:
Nursing diagnosis (patient’s needs)
List two (2)- three (3) actual and potential problems with Kevin as a nursing diagnosis
Planning (nursing intervention required)
Expected outcomes
READINGS
Students are required to refer to the following textbooks:
Gulanick & Myers (2010) textbook (Nursing care plans).
Kevin
Kevin is a 19 year old male, admitted with bilateral fractured wrists, after falling from a motor bike. He has significant pain and is anxious about being in hospital. He states that his pain score is 8/10 and is grimacing. You observe on admission that he speaks ‘gruffly’ to his family and does not engage in conversation when you introduce yourself to him. He sates he is ‘frustrated about needing help’ and ‘wants to get out of here’.
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Nursing Care Plan – Kevin
Nursing diagnosis(patient’s need)
Planning(Nursing intervention Required)
Expected Outcomes
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PART 2
STUDENT INSTRUCTIONS
Students are required to read the scenario below and develop a nursing care plan for Mr. Giovanni.
The nursing care plan requires you to consider the following:
Nursing diagnosis (patient’s needs)
Planning (nursing intervention required)
Expected outcomes
READINGS
Students are required to refer to the following textbooks:
Gulanick & Myers (2010) textbook (Nursing care plans).
Mr. Giovanni - 55yo
Having an elective surgery of Total Knee Replacement tomorrow
Has history of Type II Diabetes Mellitus
Non-English speaking background
Independent with his ADL’s
Lives alone in a unit
Has a son and daughter who are grown up in Australia, but very difficult to get in touch with
You need to complete the admission assessment and documentation
Also, the doctor wants you to carry out discharge education for Mr Giovanni
Fasting from midnight (Mr. Giovanni has not been informed yet)
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Nursing Care Plan –Mr. Giovanni
Nursing diagnosis(patient’s need)
Planning(Nursing intervention Required)
Expected Outcomes
Actual/potential problem (circle the correct response)
Actual/potential problem (circle the correct response)
Actual/potential problem (circle the correct response)
Actual/potential problem (circle the correct response)
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Activity 4: Data collection admission note – Part 1
STUDENT INSTRUCTIONS
Students are required to read the scenario below and complete the admission note using the information provided in the scenario.
HINT TIP
Students please note, this activity is part one (1) of a two (2) part activity. You must complete this after before you attempt activity one (1) Data collection (vital signs admission notes, in session two (2).
Scenario One (1)
You are admitting an Aboriginal male client to your ward for surgery this afternoon. Eddie Fisher is a forty (40) year old man and lives with his partner and their five (5) children. He sustained a knee injury playing rugby and has torn his cruciate ligament in his left knee. He walks with crutches as he is unable to weight bear.
He is well supported by his family and his partner and children. He smokes 10-15 cigarettes a day and is a non-drinker. He is anxious about his admission because he has a needle phobia.
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ADMISSION NOTES
DATE NAME
AGE ON ADMISSION
GENDER
RELIGION
CULTURE
SOCIAL SUPPORT
COPING MECHANISMS
SOCIAL
HEALTH NEEDS
ADL ASSESSMENT:
DIET
OUTPUT
MOBILISATION
HYGIENE
DIET:
OUTPUT:
MOBILISATION:
HYGIENE:
CLIENT CONCERNS AND NEEDS RE: ADMISSION
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TAKING CLIENT, HISTORIES, PHYSICAL ASSESSMENT – VITAL SIGNS
Activity 1: Data collection vital signs admission note – Part 2
STUDENT INSTRUCTIONS
Students are required to read the scenario below and determine whether the information provided is subjective data, objective data or additional information.
Record your responses on the observation chart provided.
Scenario
You are admitting an Aboriginal male client to your ward for surgery this afternoon. Eddie Fisher is forty (40) year old man and lives with his partner and their five (5) children. He sustained a knee injury playing rugby and has torn his cruciate ligament in his left knee. He walks with crutches as he is unable to weight bear.
He is well supported by his family and his partner and children. He smokes 10-15 cigarettes a day and is a non-drinker. He is anxious about his admission because he has a needle phobia.
Observation on admission were:
T: 37.0
P: 94
R: 24
BP: 110/70
HEIGHT: 178
WEIGHT: 80kg
BMI: 25
URINALYSIS: nil abnormal
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Observation Chart
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Activity 2: Vital signs quiz
STUDENT INSTRUCTIONS
Students are required to answer the following questions.
1. During the assessment stage, it is often appropriate to offer health teaching about findings, when taking vital signs. Which of the following statements, by the nurse, is the most appropriate after taking a client’s vital signs?
a) Your hypertension is under control.
b) You have pitting oedema and mild varicosities.
c) Your pulse is 80 beat per min. This is within normal range.
d) I am using my stethoscope to listen for crackles and wheezes.
2. A patient has just finished eating ice. What would be the most appropriate site to take his temperature?
a) Rectal
b) Axillary
c) Oral
d) Tympanic
3. A patient had a bilateral fracture of the wrists. The most appropriate pulse point to use would be_____________
a) The femoral artery.
b) The carotid artery.
c) The dorsalis pedis.
d) The fontanelle.
4. Normal respiratory rate for a young adult should be _____________
a) 28-40 bpm.
b) 20-28 bpm.
c) 16-20 bpm.
d) 10-14 bpm.
5. Your patient is experiencing pain from an injury, which has increased their respiratory rate. An increased breathing rate is known as____________
a) Dyspnoea.
b) Orthopnoea.
c) Tachypnoea.
d) Hypoventilation.
6. Difficulty breathing in medical terminology is known as ______________
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a) Dyspnoea.
b) Orthopnoea.
c) Tachypnoea.
d) Hypoventilation.
7. Low blood pressure in medical terminology is known as __________
a) Pulse pressure.
b) Hypertension.
c) Hypotension.
d) Systolic pressure.
8. Normal blood pressure for a young adult should be__________
a) 120 / 80.
b) 180 / 95.
c) 140 / 80.
d) 80 / 45.
9. Diastolic pressure is defined as __________
a) The wave of expansion in an artery.
b) The relaxation stage of the cardiac cycle.
c) Above the acceptable normal level.
d) The contraction phase of the cardiac cycle.
10.The term febrile is defined as ______________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
11.List four (4) variables that can affect the temperature range of adults?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
12.What is the correct practice for the collection of a urine specimen, after a ward urinalysis showed (++) leukocytes?
a) By inserting a urinary catheter.
b) MSU.
c) By inserting a needle into the bladder.
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d) Use the already collected urine used for urinalysis.
13.Why is routine mid-stream urine collected at the time of a client admission?
a) Establish a diagnosis.
b) Establish baseline observations.
c) Establish the volume of urine.
d) Establish the patient’s voiding pattern.
14.What Information is normally recorded after performing a routine urinalysis?
a) SG, pH, clarity & colour.
b) Blood, volume, clarity & pH.
c) Leucocytes, blood, volume & clarity.
d) Specific gravity, pH, volume, clarity, odour & colour.
15.What one (1) abnormality would you expect to be present in the urine, if a patient had a urinary tract infection?
a) Leukocytes.
b) Glucose.
c) Urobilinogen.
d) Ketone bodies.
16.What is the appropriate procedure for sending the sample to the laboratory, after MSU collection?
a) Leave labelled specimen in the pan room, until someone has time to collect it.
b) Double bag the specimen and send to the lab immediately.
c) Place the labelled specimen jar into a transport bag and take to the appropriate collection site.
d) Double bag the specimen and place in the refrigerator.
17.Neurovascular observations are completed on Sebastian. What are the components of Neurovascular observations that the EN can assess?
a) Colour, temperature, pain, sweating and pulse.
b) Colour, temperature, movement, sensation and pulse.
c) Pulse, sweating, sensation, pain and pressure.
d) Colour, movement, pulse, pressure and dexterity.
18.Identify two (2) common tools, used to assess pain?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_________
19.List two (2) common objective data, you may collect when a patient is in pain?
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___________________________________________________________________________________________________
___________________________________________________________________________________________________
_________
20.What does a Blood Glucose Level (BGL) of 13mmol/l indicate?
a) Hyperglycaemic.
b) Higher than normal but satisfactory for some patients.
c) Hypoglycaemic.
d) Within the normal range for diabetes mellitus.
21.Presence of Ketones in urine indicates, that inadequate insulin may _________
a) Cause protein in muscle to be used to produce energy.
b) Lead to breakdown of fats to provide an alternative source of energy.
c) Result in excessive breakdown of carbohydrates for energy.
d) Allow an increase in the production of amino acids for energy.
22.What is considered to be a normal range for Blood Glucose Levels (BGLs)?
a) 2-4 mmols
b) 4-8 mmols
c) 8-13 mmols
d) 13-19 mmols
23.List the normal ranges for adult vital signs?
Normal ranges for adult vital signs
T RR
HR BP
SpO2
24.What are two (2) health risks associated with a low BMI?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_________
25.What are two (2) health risks associated with a high BMI?
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___________________________________________________________________________________________________
___________________________________________________________________________________________________
_________
Activity 3: Data collection - skin integrity assessment
PART 1
STUDENT INSTRUCTIONS
Students are required to read the scenario below and determine whether the information provided is subjective data, objective data or additional information.
Record your responses in the table provided.
Scenario
You are looking after an elderly client, Mavis Berkely, 84yo female with urinary incontinence. She is 170cm, weight 60kg, BMI 18. She has bony prominences to her hips, coccyx and shoulders. She is bed-ridden following a stroke and has limited sensation to her left side. She eats small meals and needs encouragement. When she sits out in a chair she tends to slump and slide and therefore needs frequent re-positioning.
Subjective data Objective data Additional information gathered
PART 2
STUDENT INSTRUCTIONS
Students are required to read the scenario below and complete a Braden Scale skin integrity assessment.
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Scenario
You are looking after an elderly client, Mavis Berkely, 84yo female with urinary incontinence. She is 170cm, weight 60kg, BMI 18. She has bony prominences to her hips, coccyx and shoulders. She is bed-ridden following a stroke and has limited sensation to her left side. She eats small meals and needs encouragement. When she sits out in a chair she tends to slump and slide and therefore needs frequent re-positioning.
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BRADEN SCALE SKIN INTEGRITY ASSESSMENT (circle the correct answers)
SEVERE RISK: Total score 9 HIGH RISK: Total score 10-12
MODERATE RISK: Total score 13-14 MILD RISK: Total score 15-18
DATE OF ASSESSMENT:
SENSORY PERCEPTION
Ability to respond meaningfully to pressure-related discomfort
1. COMPLETELY LIMITED – Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation, OR limited ability to feel pain over most of body surface.
2. VERY LIMITED –Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body.
3. SLIGHTLY LIMITED –Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.
4. NO IMPAIRMENT – Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
MOISTURE
Degree to which skin is exposed to moisture
1. CONSTANTLY MOIST– Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.
2. OFTEN MOIST – Skin is often but not always moist. Linen must be changed at least once a shift.
3. OCCASIONALLY MOIST – Skin is occasionally moist, requiring an extra linen change approximately once a day.
4. RARELY MOIST – Skin is usually dry; linen only requires changing at routine intervals.
ACTIVITY
Degree of physical activity
1. BEDFAST – Confined to bed. 2. CHAIRFAST – Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.
3. WALKS OCCASIONALLY – Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.
4. WALKS FREQUENTLY– Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.
MOBILITY
Ability to change and control body position
1. COMPLETELY IMMOBILE – Does not make even slight changes in body or extremity position without assistance.
2. VERY LIMITED – Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.
3. SLIGHTLY LIMITED – Makes frequent though slight changes in body or extremity position independently.
4. NO LIMITATIONS – Makes major and frequent changes in position without assistance.
NUTRITION
Usual food intake pattern
1. VERY POOR – Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement,
2. PROBABLY INADEQUATE – Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary
3. ADEQUATE – Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally refuses a meal, but will usually take a supplement if offered,
4. EXCELLENT – Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
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supplement
FRICTION AND SHEAR 1. PROBLEM- Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.
2. POTENTIAL PROBLEM– Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
3. NO APPARENT PROBLEM – Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.
Total Score
Source: Barbara Braden and Nancy Bergstrom. Copyright, 1988. Reprinted with permission.
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URINALYSIS, SPECIMEN COLLECTION & PAIN ASSESSMENT
Activity 1: Urinalysis and specimen collection
STUDENT INSTRUCTIONS
Students are required to complete the following questions.
1. What are the normal ranges of urinalysis?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________
2. What are the differences in between performing urinalysis and collecting MSU?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________
3. What three (3) features are checked with a visual examination of a urine specimen?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________
4. Fill in the blanks.
Incontinent Soiling Perineal area Elimination
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Perineal care is cleansing of the _____________________________ – a hygiene and comfort
measure. It is done during the daily bath as well as anytime it is necessary due to
________________ during _______________ or _______________ episodes.
5. Gathering equipment is a time-management strategy. What types of equipment would have to gather when conducting urinalysis?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_______________
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Activity 2: Pain assessment
PART 1
STUDENT INSTRUCTIONS
Instructions for nurses
Pretend that you are working in the hospital so that it is necessary to talk to the patient in an appropriate manner. You will need to ask PQRST, to perform a thorough pain assessment.
Students are required to:
1. Take turns at being a patient and the nurse. Use all three (3) pain assessment tools with different types of pain.
2. Talk to your patient in the appropriate manner and language.
3. Patient role must pretend that you are in pain.
4. Practice using common pain assessment tools as below as well as “PQRST”
** remember these tools are to assess the intensity/ “severity” of the pain only
PQRST (Examples of questions for PQRST for nurse’s use)
P: What were you doing when the pain started?
Possible response
I was just lying in my bed resting
Q: Can you describe your pain? Is it sharp? Dull? Stabbing like?
Possible response
It is aching
R: Does the pain spread anywhere? Can you show me where it goes?
Possible response
It is goes around my ribs, here to there
S: How bad is your pain? Can you scale 0-10? 0 is no pain 10 is the worst pain you have ever experienced.
Possible response
It is six (6) out of ten (10)
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T: How long did the pain last? Is it still there or comes and goes?
Possible response
It is always there
Other possible responses
I do not speak English!
I not understand!!!
I have pain!
Very bad!!
.............. no response
sad face
sobbing or occasional moan
Rigid
Use your imagination……
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Visual Analogue Scale (VAS)
Cover the numbered scale.
Do not show the patient the numbered scale.
Instruct the patient to point to the position on the line between the faces, to indicate how much pain they are currently feeling. The far left end indicates ‘No pain’ and the far right end indicates ‘Worst pain ever’.
Numerical rating scale (NRS)
Instruct the patient to choose a number from 0 to 10, which best describes their current pain.
0 would mean ‘No pain’ and 10 would mean ‘Worst possible pain’.
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Faces rating scale (FRS)
Cover the numbered scale.
Do not show the patient the numbered scale.
Adults, who have difficulty using the numbers on the visual/numerical rating scales, can be assisted with the use of the six facial expressions, suggesting various pain intensities. Ask the patient to choose the face that best describes how they feel. The far left face indicates ‘No hurt’ and the far right face indicates ‘Hurts worst’. Document the number below the face chosen.
PART 2
STUDENT INSTRUCTIONS
Students are required to role play the following activity.
This is an activity-related score. Observe your patient while performing an activity related to their painful area (for example, deep breathe and cough for thoracic injury or move affected leg for lower limb pain). Normally performed as a part of vital signs.
Students are required to:
1. Take turns at being a patient and a nurse
Functional activity score
A – No limitation meaning the patient’s activity is unrestricted by pain
B – Mild limitation means the patient’s activity is mild to moderately restricted by pain
C - Severe limitation means the patient ability to perform the activity is severely limited by pain
** Relative to baseline refers to any restriction above any pre–existing condition the patient may already have.
Abbey Pain scale
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PART 3
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STUDENT INSTRUCTIONS
Students are required to role play the following activity. You will need to pretend that your patient is unable to provide a self-report of pain: scored 0–10 clinical observation. Using this information, complete the Behavioural Rating Scale below.
Students are required to:
1. Take turns at being a patient and a nurse
Behavioural Rating Scale
Face 0
Face muscles relaxed
1
Facial muscle tension, frown, grimace
2
Frequent to constant frown, clenched jaw
Face score:
Restlessness 0
Quiet, relaxed appearance, normal movement
1
Occasional restless movement, shifting position
2
Frequent restless movement may include extremities or head
Restlessness score:
Muscle tone* 0
Normal muscle tone
1
Increased tone, flexion of fingers and toes
2
Rigid tone
Muscle tone score:
Vocalisation** 0
No abnormal sounds
1
Occasional moans, cries, whimpers and grunts
2
Frequent or continuous moans, cries, whimpers or grunts
Vocalisation score:
CONSOL ability 0
Content, relaxed
1
Reassured by touch, distractible
2
Difficult to comfort by touch or talk
CONSOL ability score:
Behavioural pain assessment scale total (0–10) /10
* Assess muscle tone in patients with spinal cord lesion or injury at a level above the lesion injury. Assess patients with hemiplegia on the unaffected side. ** This item cannot be measured in patients with artificial airways.
Functional activity score#
(Cough/movement)A – No limitationB – Mild limitationC – Severe limitation
#Relative to baseline
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NEUROLOGICAL & NEUROVASCULAR OBSERVATIONS & BGL
Activity 1: Specific observation
PART 1
STUDENT INSTRUCTIONS
Students are required to answer the following questions.
1. Is it normal to see Leukocytes in urine? What is the indication if presence?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
__________________________________________________________________________________
2. What is the normal pH of urine?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
3. What does pH measure?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
4. What is normal specific gravity reading?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
5. When would be the occasion the urine has low or high reading of specific gravity?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
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6. What could the presence of bilirubin in urine indicate?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
7. What is the normal range for blood glucose level?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
8. What are ketones?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
9. What do ketones in the urine indicate?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
10.Define MSU.
________________________________________________________________________________________________________
__________________________________________
11.What would you do with a urine specimen once you have obtained it?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
12.Demonstrate on your partner how you would assess Glasgow Coma Scale (GCS) when performing neurological observations on a client.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
13.What does a score of three (3) indicate on the GCS?
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________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
14.Assume the person sitting beside you has been to a surgical procedure for closure of a compound fracture of their R) wrist – perform a set of neurovascular observations on their R) wrist.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
15.Perform pain assessment on your partner. (Use PQRST and numeric pain scale)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
16.Why do we record a client’s height and weight?
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
17.Define BMI.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
18.Write the formula for calculating BMI.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
19.Identify the BMI range for underweight, normal, overweight and obese?
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________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
20.Calculate BMI for someone who is 165cm tall and weighs 90 kg.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
____________________________________________________________________________________
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5252
Activity 2: Neurological observations (Lab practice)
STUDENT INSTRUCTIONS
Let’s get practical!
Use the chart below during the discussion, and record the result when you perform a neurological observation with your patients (other students in your group).
A list of possible neurological response has been provided below. The student who is role playing as a patient may use each cue card as a response during the assessment
Eye: Spontaneously
Verbal: Orientated
Motor: Obey Command
R) &L) arm & legs: full strength
Eye: To pain
Verbal: None
Motor: Extension
R) &L) arm & legs: extension to pain
Eye: To speech/name
Verbal: Orientated
Motor: Obey Command
R) &L) arm & legs: full strength
Eye: To pain
Verbal: None
Motor: abnormal flexion
R) &L) arm & legs: flex to pain
Eye: To Pain
Verbal: Incoherent
Motor: Localise Pain
R) & L) arm: moderate weakness
R)& L) Leg : No response
Eye: None
Verbal: None
Motor: None
R) &L) arm & legs: No response
Eye: To speech/name
Verbal: Confused
Motor: Localise Pain
R)& L) arm: full strength
R)&L) Leg: Mild weakness
Eye: To speech/name
Verbal: inappropriate
Motor: Localise Pain
R) arm: flex to pain
L) arm extension to pain
R) leg: flex to pain
L) Leg extension to pain
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Eye: To pain
Verbal: Orientated
Motor: Obey Command
R) &L) arm & legs: full strength
Eye: Spontaneously
Verbal: Confused
Motor: Obey commands
R) arm: severe weakness
L) arm extension to pain
R)+L) leg: severe weakness
Eye: To pain
Verbal: inappropriate
Motor: Withdraws
R) arm: mild weakness
L) arm: full strength
R)+L) leg: full strength
Eye: Spontaneous
Verbal: inappropriate
Motor: Localise Pain
R)+L) arm flex to pain
R)+L) Leg flex to pain
Eye: To pain
Verbal: incoherent
Motor: abnormal flexion/flex to pain
R)+L) flex to pain
R)+L) flex to pain
Eye: None
Verbal: None
Motor: Extension
R) arm: extension to pain
L) arm: flex to pain
R) leg: extension to pain
L) Leg : flex to pain
Eye: To pain
Verbal: None
Motor: Withdraws
R)+L) Extension to pain
Eye: To speech/name
Verbal: inappropriate
Motor: Obey Command
R)+L) arm: severe weakness
R)+L) Leg: moderate weakness
Eye: Spontaneously
Verbal: Orientated
Motor: Obey Command
R) &L) arm & legs: full strength
Eye: To pain
Verbal: None
Motor: Extension
R)+L) arm & leg extension to pain
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5454
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5555
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ADMISSION & DISCHARGE PLANNING
Activity 1: Admissions with different age groups
STUDENT INSTRUCTIONS
Students are required to summarise the hospital admissions process for each of the following age groups:
Children
Adolescents
Adults
Older adults
Each summary should include;
Psychological impact due to hospital admission
Factors that may be affected, due to hospitalisation
Nursing management to alleviate the impacts (DO NOT use the word “reassurance”, provide specific management methods)
READINGS
Students are required to refer to the following textbook:
Tabbner’s 2013 (Chapter 19)page 334-337, 340-343
Children
Adolescents
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Adults
Older Adults
Activity 2: Nursing care plans and development stages
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STUDENT INSTRUCTIONS
Students are required to read the follow case studies and answer the questions provided below.
Older Adult
Mrs. Caroline is an eighty-five (85) year old women, who has a long term history of COPD, for
which she wears home oxygen 1L/min via nasal prongs and takes Seretide MDI (1 puff) daily.
She slipped and fell in her bathroom at home two weeks ago. She was diagnosed with orthostatic
hypotension. Mrs. Caroline has been transferred to the rehabilitation ward where you are
currently working.
On arrival to the ward, Mrs. Caroline is withdrawn and looks upset and worried. She relays to you
that is she is very nervous about getting her strength back within a certain period of time and
fearful about returning home by herself. She arrived to the ward by a patient transport
(ambulance) and was accompanied by her daughter who lives a twenty (20) minute away drive
from Mrs. Caroline’s house.
Observation on admission were:
T: 35.6 C P: 60 R: 18 BP: 92/56mmHg HEIGHT: 170 WEIGHT: 65kg BMI: 19 URINALYSIS: awaiting urination HR: 110 bpm RR: 24 bpm SpO2: 94% on 1L/min via nasal prongs
1. List four (4) specific health needs for Mrs. Caroline’s age group.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
2. List three (3) actual and three (3) potential problems with Mrs. Caroline, as a nursing diagnosis.
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___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
3. Write admission note for Mrs. Caroline.
ADMISSION NOTES
DATE NAME
AGE ON ADMISSION
GENDER
RELIGION
CULTURE
SOCIAL SUPPORT
COPING MECHANISMS
SOCIAL
HEALTH NEEDS
ADL ASSESSMENT:
DIET
OUTPUT
MOBILISATION
HYGIENE
DIET:
OUTPUT:
MOBILISATION:
HYGIENE:
CLIENT CONCERNS AND NEEDS RE: ADMISSION
ADMISSION OBSERVATIONS:
T:
P:
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T P R BP HEIGHT WEIGHT BMI URINALYSIS
R:
BP:
HEIGHT:
WEIGHT:
BMI:
URINALYSIS:
HR:
RR:
SpO2:
NURSING NOTES:
(sign off with name, signature and delegation at the end of the notes)
Middle-aged Adulthood
Mr. Grey is fifty-five (55) year old male, who is newly diagnosed with Type 2 diabetes mellitus. His height is 175cm and weighs 101kg. He informs you that he has no idea what diabetes is. He does not know how he is going to look after himself at home. He has three (3) children who are 24, 21 and 16 year old. He is very concerned that the latest diagnosis can affect his working ability and financial situation. He knows that he needs to lose weight, but he is not very committed to regular exercise.
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1. List four (4) major physiological changes that occur in his developmental stage.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
2. List two (2) specific health needs for Mr. Grey’s age group.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
3. List four (4) needs to be considered for Mr. Grey’s discharge, and write a discharge plan.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
4. Discuss how you would educate Mr. Grey about his concerns and medical condition.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
Young Adulthood
Barbara is twenty-nine (29) year old female, who presents with nausea, frequency and burning with urination. Barb also has lower back pain. She states ‘my back is sore, in the middle, down on the right hand side’. Her pain score is 3/10 and she is febrile. Her vital signs are: PR 92 beats per minute, BP 140/90mmHg, RR 20 breaths per minute. Temp 37.9 C.
Barbara states that she has ‘been to the toilet to urinate four times in the last half hour’. You observe that Barbara is restless and unable to sit still, and keeps moving her legs when she does sit. Barbara appears anxious. She states ‘it stings every time I go and when I finish I feel like I need to go again’. She reports ‘I feel sick – waves of nausea’, but she has not vomited.
1. List three (3) actual and three (3) potential problems with Barbara, as a nursing diagnosis.
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___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
2. List major developmental stages that may be seen with Barbara.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________
Adolescence
Ben is a thirteen (13) year old male brought to an emergency department by his mother, after reporting vomiting and abdominal pain. You have collected the information that he had polyuria and excessive thirst, accompanied by a 3kg weight loss over the last two (2) weeks. His BGL was 21mmol/L on arrival and has come down to 15.8 mmol/L after administration of insulin. He was diagnosed with a Hyperglycaemic diabetic episode.
He has transferred to the paediatric ward for further management. On arrival to the ward, he is crying and upset. He is holding his arm and states that he has had enough with ‘being so sick and fat!’ He also states, ‘I didn’t have to come to hospital’, ‘I’m too scared, being away from home’ and ‘I don’t like the smell of hospitals, it makes me feel sick’. His mother tells you that Ben was skipping his meals, as someone from school was teasing him about being ‘chubby’.
Ben was prescribed an insulin regimen, consisting of an insulin injection before breakfast and before bed. He also has to measure blood glucose levels four (4) times a day, from the day of discharge, onwards.
1. Identify four (4) health risks/major issues, associate with this developmental age.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
3. List four (4) growth and developments that may be seen with Ben during middle adolescence.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
4. List three (3) actual and three (3) potential problems with Ben as a nursing diagnosis.
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___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
Childhood
Mackenzie is a five (5) year old girl, being admitted for an acute asthma attack. She is the youngest of three children – all girls. Her parents are Debra and Hugh. Mackenzie’s older sister is ten (10) and has a disability that requires her mother’s constant care. Her middle sister is seven (7). Debra is a stay at home mother and Hugh works full time as an Electrician and part-time packing shelves at the local grocery store. Hugh works very from7am-11pm five (5) days per week. Debra is the primary care giver of the children.
According to Debra, Mackenzie is a ‘happy and well-adjusted child.’ She has just completed her Prep year at school. Her immunisations are up to date and she is achieving well in all her developmental milestones. Mackenzie has had asthma since she was very young and once a year, experiences an episode severe enough to require hospitalisation.
1. Discuss the impact of hospitalisation for Mackenzie and her family.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
2. Identify three (3) factors that influence the way a child and their family react when a child needs to be hospitalised.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________
3. List two (2) actual and two (2) potential problems with Mackenzie, as a nursing diagnosis.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
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CLIENT ASSESSMENT SKILLS
Activity 1: LAB case scenarios
STUDENT INSTRUCTIONS
Let’s get active!
The following activities will need to be completed in a clinical lab session. Educators will have practical stations organised. There are five (5) practical stations, they are as follows:
Station one (1) – Holistic assessment
Station two (2) – Neurovascular observations
Station three (3) – Urinalysis
Station four (4) – Neurological observations
Station five (5) – Blood Glucose test
Each station will require you (the student) to:
1. Read the LAB case scenarios BEFORE partaking the practical component.
2. Complete three (3) to four (4) questions BEFORE you perform the clinical skills
3. Form groups of three (3) to four (4) people. One (1) person is required to play the role of patient.
4. Each student MUST take turns in playing the nurse and the patient.
5. Students are required to complete the required skills check. Once you have completed a skills task, tick the corresponding skill. An example has been provided below.
HINT TIP
The following exercise will provide you with the necessary knowledge and practical/clinical skills required for your upcoming OSCE exam.
READINGS
Students are required to refer to the following textbook:
Essential Clinical Skills
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Station one (1) Holistic assessment
Mr. Chen is forty-four (44) year old Chinese man, who migrated to Australia twenty-five (25) years ago. Mr. Chen has been referred to the hospital for various investigations of prostate cancer. Mr. Chen comes from a strict catholic background and he feels very insecure that he could not go to church last Sunday due to the illness. He has a long term history of Chronic Obstructive Pulmonary Disease, type 2 Diabetes Mellitus and peripheral vascular disease. Mr. Chens’s uncle died from prostate cancer five (5) years ago. He tells you that he does not want any family members to find out about the investigations and any results at this stage. He has urgency of urination. He is getting angry at himself for neglecting his health.
Socioeconomic: Mr. Chen lives with his wife and two (2) teenage sons. He works in a trading company as a manager and travels in between China and Australia almost every month.
Before you perform the clinical skills, please complete the questions below in your group.
1. Normal ranges of temp, BP, HR, RR and Sp02 are?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
2. What is a holistic assessment? What information do you need to collect?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
3. What are some legal and ethical considerations with Mr. Chen’s case?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
Students are required to complete the listed skills. Once you have completed a skills task, tick the corresponding skill.
For example:
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Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to the patient
Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to Mr. Chen
Skill two (2) Complete a holistic assessment
Skill three (3) Obtain vital signs
Skill four (4) Record the outcome into an observation chart/vital sign chart
Things I can improve on:
Things I did well:
Station two (2) Neurovascular observations
Sebastian is an 18 year old male, admitted with bilateral fractured wrists, after falling from a motor bike. He had an operation for the fixation (2) weeks ago and the RMO has informed the
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nurse in charge that he is safe to be discharged today. The RMO has requested you to perform a last set of neurovascular observations, before he is discharged.
Before you perform the clinical skills, please complete the questions below in your group.
1. What are the five (5) Ps assessed with neurovascular observations?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
2. What areas should the nurse check and complete at the time of patient discharge?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
__________________
3. Record the outcome into the neurovascular observation chart below.
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Students are required to complete the listed skills. Once you have completed a skills task, tick the corresponding skill.
For example:
Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to the patient
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Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to Sebastian
Skill two (2) Perform a set of neurovascular observations on Sebastian
Skill three (3) Record the outcome into the neurovascular observation chart
Skill four (4) Go through the discharge process
Things I can improve on:
Things I did well:
Station three (3) Urinalysis
Naomi is a 47 year old woman who presents with nausea, frequency and burning
when urinating. Naomi also has lower back pain. She states ‘my back is sore, in the
middle, down on the right hand side’. Her pain score is 3/10 and she is febrile. Her
vital signs are: PR 92 beats per minute, BP 140/90mmHg, RR 20 breaths per minute.
Temp 37.9degrees Celsius.
Naomi states that she has ‘been to the toilet to urinate four times in the last half
hour’. You observe that Naomi is restless and unable to sit still and keeps moving
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her legs when she does sit. Naomi looks anxious. She states ‘it stings every time I go
and when I finish I feel like I need to go again’. She reports ‘I feel sick – waves of
nausea’. She has not vomited.
Before you perform the clinical skills, please complete the questions below in your group.
6. What are the normal ranges of urinalysis?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
7. What are the differences in between performing urinalysis and collecting MSU?
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___________________________________________________________________________________________________
___________________________________________________________________________________________________
_________
8. What three (3) features are checked with a visual examination of a urine specimen?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
Document the results in the table below:
Urinalysis Date:
Colour
Odour
Foreign substances
S.G (specific gravity)
pH
Protein
Glucose
Ketones
Bilirubin
Blood
Students are required to complete the listed skills. Once you have completed a skills task, tick the corresponding skill.
For example:
Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to the patient
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Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to Naomi
Skill two (2) Explain the purpose of urinalysis to Naomi
Skill three (3) Perform urinalysis
Skill four (4) Document the results
Things I can improve on:
Things I did well:
Station four (4) Neurological observations
Mr Jays is a seventy-eight (78) year old man, who is admitted via the ambulance to hospital,
after collapsing at home. He lives alone and has two (2) adult sons, who visit fortnightly. He has
a past history of a cerebrovascular disease with some (L) sided weakness. His height is 182 cm
and his weight is 78kg.
Before you perform the clinical skills, please complete the questions below in your group.
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1. What four (4) areas are assessed with neurological observations?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
2. What are the indications for performing neurological observations?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
3. What does BMI stand for?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
4. What is the formula for calculating BMI?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
4. Record the outcome onto the neurological observation chart below.
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Students are required to complete the listed skills. Once you have completed a skills task, tick the corresponding skill.
For example:
Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to the patient
Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to Mr. Jays
Skill two (2) Explain the purpose of the neurological observations to Mr. Jays
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Skill three (3) Perform full set of neurological observation, including vital signs
Skill four (4) Record the result by completing a neurological observation chart
Skill five (5) Calculate BMI of Mr. Jays
Things I can improve on:
Things I did well:
Station five (5) Blood Glucose test
Mr James Matson is a seventeen (17) year old male, who has presented to the emergency
department with blurred vision, drowsiness, urinary frequency, dizziness and extreme thirst.
James has Type 1 Diabetes Mellitus and it is suspected that he is hyperglycaemic.
Before you perform the clinical skills, please complete the questions below in your group.
1. Identify acceptable parameters for BGL’s.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________
2. Identify two (2) health impacts of unstable diabetes control.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
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___________________________________________________________________________________________________
________________________________________________
3. Record the outcomes onto a progress note.
Students are required to complete the listed skills. Once you have completed a skills task, tick the corresponding skill.
For example:
Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to the patient
Required skills check Check list(Please tick)
Skill one (1) Introduce yourself to James
Skill two (2) Explain the purpose of the blood glucose test
Skill three (3) Perform a blood glucose test
Skill four (4) Document the results
Skill five (5) Report any abnormalities to the RN (educator)
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Things I can improve on:
Things I did well:
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Please leave blank
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