NCP106 Nursing Care Plans Assignment-Think Education Australia.

Course: HLT54115 Diploma of Nursing
Subject Code and Title: NCP106_Nursing care plans
Unit(s) of Competency: HLTENN004
Performance criteria,Knowledge evidence and
Performance assessed:PC: 1.1, 1.2, 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 3.1, 3.3, 4.1.
PE:1, 3. KE: 1, 2, 3, 4, 7, 8.
Title of Assessment Task: Assessment 1, Part A: Case Study
Type of Assessment Task: Short Response
Length: As indicated in each question
Submission: Due by the end of Module 3 (Week 7)
NCP106 Nursing Care Plans Assignment-Think Education Australia.

Task Instructions:
To complete Assessment 1, Part A, provide your responses to the questions on the Assessment Response Template below. These short response questions are based on the information received in the case study.
Your responses must be typed into the spaces provided beneath each question, and the whole document must be submitted to Blackboard as your response to Part A.

These questions must be answered in full. When responding to the questions, please pay attention to the entire question being asked, as well as the prescribed word count, if provided. You are required to use the
correct medical terminology when answering all questions and well as referring to your assessment charts.Provide nursing rationales for each nursing intervention.

All answers must be referenced in alignment with Think Education policy.

You will be assessed on your responses and will be deemed as either satisfactory or not satisfactory. ALL your responses must be marked as satisfactory in order to pass both assessments. If your assessment is not
deemed satisfactory, you will be re-assessed as per the THINK Education Assessment Policy for Vocational Education and Training (VET), before being awarded a Non Satisfactory mark for the assessment and the
unit.

Scenario:Mr.xxx
I: Mr xxx is a 53 year old Male,
S: He was brought to the Emergency Department by ambulance at 2130 hrs on Saturday evening, after sustaining a fall at home. Mr xxx lives with his wife, who was not present at the time of the fall. On Mr xxx arrival home, she found Mr xxx on the floor and called the ambulance.Mr xxx is experiencing pain in his Left Knee, he is unable to weight bear on his left leg and is unsteady.He states he is feeling dizzy and unstable when attempting to stand upright. It is unclear if he hit his head in the fall as he states he “Felt dizzy when going to the bathroom and I think I blacked out”.
B: Mr xxx past Medical History (PM Hx) include:
 Type ll Diabetes needing close management
 Osteoarthritis in L) Knee
 Peripheral vascular Disease (PVD)
 Chronic Obstructive Airway disease (COPD)

NCP106 Nursing Care Plans Assignment-Think Education Australia.

Social History (SHx):
 Occupation Long Haul truck driver
 ETOH (Alcohol) usage on a regular basis
 Smoker, averages 15/20 cigarettes per day
 Often consumes take away/ fast food diet as away from home regularly

A: Mr xxx is 135 kg and 170 cm in height. Current vital signs Resp 17, O 2 Sats 96% on room air (RA), BP 150/100, HR 99, Temp 36.9, BGL 7.8 mmol/L , GCS 15.
R: Further orders include;
X-Ray of L) Knee shows significant advancement of Osteoarthritis, requiring further investigation, pain score is currently 8/10, End one 10 mg administered orally for pain relief at 2210 hrs with little effect, neuro vascular observations commenced and GCS score currently 15.

Further investigation of Osteoarthritis in L) knee needs to be arranged. Referrals for the Physiotherapist, dietician, social worker, diabetic educator and endocrinologist are to be arranged via e MR (electronical medical
record). Regular pain relief as charted
 2/24 Vital signs
 2/24 Neurological observations
 2/24 neurovascular observations on L) leg
 Non weight bearing on L) Leg
 Full assistance with ADLs  TEDs to be applied
 Braden score to be assessed

Mr xxx was transferred to the Med/Surgical ward at 0730 hrs and you have received handover for this patient and are require to complete the following.

Question 1
Referring to the information provided in Mr xxx case study, complete the nursing admission form, on the template provided below, using appropriate medical terminology. Ensure the documentation meet legal requirements.

Question 2
As a new admission to your ward, you need to plan appropriate care for Mr xxx, based on the information received in the case study. Use the template below to outline the anticipated care for Mr xxx taking into account your EN Scope of Practice. To complete this question you need to:

• Specify four (4) nursing diagnoses or risk factors associated with the client’s current health presentations. (Consider BMI, Manual Handling, non-weight bearing on Left leg due to osteoarthritis, current vital signs, pain score, poor diet/ take away foods, Type ll Diabetes requiring close monitoring, smoker, SOB on excursion, COPD, PVD, recently experiencing dizziness on standing upright.)
• Record at least two (2) nursing interventions that could be applied for each diagnosis, these interventions must be in lines with current best practice standards.
• Specify at least one (1) member of the multi – disciplinary team that may be able to support your suggested interventions.
• Note at least one (1) expected outcomes that you would hope for as a result of each intervention. (Consider SMART goals when discussing outcomes)

Question 3 (word limit 300 words)
Mr. xxx is not able to weight bear or mobilise very well. He is mostly restricted to bed due the pain in his left knee. The NCP indicates that Mr xxx is for a sponge in bed and requires full bed sheet change. He currently has a pain score of 7/10.

How could you encourage independence for Mr xxx and ensure he is able to actively assist with his own personal care?

In your answer consider areas of:

• Privacy and dignity considerations
• Gaining informed consent and appropriate language.
• Pain management prior to initiating care
• oral hygiene and grooming Safety considerations for Mr xxx due to his obesity and BMI of 47, consider manual handling requirements.

NCP106 Nursing Care Plans Assignment-Think Education Australia.

Question 4 (word count 300 words)
Mr xxx has been identified as being in the higher range of BMI. Calculate Mr xxx BMI. With your result, discuss the appropriate strategies to protect his integumentary system and prevent skin breakdown.Consider what nutritional requirements should be discussed with Mr xxx considering his obesity, Type II diabetes and poor dietary intake. Which members of the multi-disciplinary team can assist with support and education for Mr xxx?

In your discussion consider the following:

• Document your calculated BMI
  Also consider the following in you answer:
• What is Mr xxx Braden score? What are his contributing risk factors?
• Nursing interventions that could be used to decrease Mr xxx risk factors for pressure injuries in line with best practice.
• What information should be provided to Mr xxx in relation to his current dietary choices? Who could assist you with this?

Question 5
Mr xxx has pre-existing COPD and on examination you observe that his O 2 saturations on room air are 91%. Consider your nursing interventions, within your EN scope of practice. How could you assist Mr xxx with ease of respiratory functioning whilst lying in bed and sitting out in the chair?

In your discussion consider the following:

• What are the ‘normal’ ranges for this measurement, comment on Mr xxx’s ranges compare to his SpO 2 on admission, and state what actions you need to take.
• How would you demonstrate/ explain the importance of deep breathing exercises and coughing exercises to the client.
• Which MDT member could assist with active exercises to aid Mr xxx breathing?

Question 6
Mr xxx has pre-existing osteoarthritis in his L) Knee and is currently on non-weight bearing activities.Consider your nursing interventions for a client who is unable to weight bear, within your EN scope of practice.
How could active and passive movement exercises decrease his risk of DVTs (Deep Vein Thrombosis) and VTEs (Venous Thromboembolism/ PE’s)?Consider the following in your answer;
 Active and passive exercises whilst not mobile.
 Which multi – disciplinary member can assist you with implementing the proposed care?
 What other VTE Prevention measures would be implemented?

Question 7
Mr xxx is generally an active man prior to his admission. Since being admitted to hospital Mr xxx has voiced his concern over being unable to sleep due to his inactivity and discomfort. What nursing interventions could you implement to promote comfort, rest and adequate sleep for Mr xxx? Consider the following in your answer;
 Pain management strategies
 Alternative therapies
 Mr xxx’s environment

NCP106 Nursing Care Plans Assignment-Think Education Australia.

Question 8
The medical officer has reviewed Mr xxx and recommended that he can commence mobilising for short distances.
Discuss possible safety concerns for Mr xxx as he commences mobilising, what equipment could assist to provide a safer environment and which MDT professional who could you refer Mr xxx to.