General Instructions:
Complete the following questions to demonstrate knowledge required to effectively care for a client with an acute condition All answers were applicable must include APA referencing both in text and in a reference list
HLTENN011 Implement & Monitor A Man With Acute Health Problems.
Assessment Criteria:
To achieve a satisfactory result, your assessor will be looking for your ability to demonstrate the following key skills/tasks/knowledge to an acceptable industry standard.
HLTENN011 Implement & Monitor Care For A Person With Acute Health Problems.
Number of Attempts:
You will receive up to two (2) attempts at this assessment task. Should your 1 st attempt be unsatisfactory (U), your teacher will provide feedback and discuss the relevant sections / questions with you and will arrange a due date for the submission of your 2 nd attempt. If your 2 nd submission is unsatisfactory (U), or you fail to submit a 2 nd attempt, you will receive an overall unsatisfactory result for this assessment task. Only one re- assessment attempt may be granted for each assessment task.
HLTENN011 Implement & Monitor Care For A Person With Acute Health Problems.
Instructions for the Assessor
<outline the conditions under which the assessment must be conducted; this should be detailed enough for multiple assessors to consistently implement the assessment and may include:
- Specifications of assessment
- equipment or material requirements
- details of location
- time restrictions
- level of assistance permitted (if any)
- WHS requirements
- physical conditions
- interactions with team members, supervisors, clients/customers
- contingencies if conditions cannot be met
<examples – The student must be provided access to techniques, procedures, information, resources and aids which would normally be available in the workplace; A work health and safety check of the assessment environment is to be conducted prior to the assessment and any hazards addressed appropriately.>
HLTENN011 Implement & Monitor Care For A Person With Acute Health Problems.
Part A – CASE STUDY
Mr Jones is a 76-year-old man with a history of smoking who was admitted to an acute care ward with a history of severe abdominal pain of approximately six hours. Mr Jones exhibits tenderness of the left lumbar/epigastric region and describes his pain as sharp and rated as 7 out of 10. On assessment, you notice Mr Jones’s abdomen has become distended and auscultation reveals no bowel sounds. He is tachycardic 115, hypertensive 165/80, febrile 38.5 o C and tachypnoeic 26.
Mr Jones begins to vomit. You contact the surgical registrar immediately. After the registrar assesses him, an abdominal X-ray and ultrasound is taken and insertion of a nasogastric tube NGT is ordered. You are required to insert a Salem-sump NGT, place it on free drainage and document in the notes.
It has been documented by the surgical registrar that Mr Jones needs be kept strictly Nil by Mouth (NBM) until review by a surgeon and a strict fluid balance chart needs to be maintained.
HLTENN011 Implement & Monitor Care For A Person With Acute Health Problems.
Part A Case study – Questions
1.Please discuss why it is important to be aware of Mr Jones history prior to going to theatre?
2.What are three (3) common abdominal complications that may require insertion of a NGT for abdominal drainage?
3.What nursing interventions are required when caring for a patient with a NGT?
4.Why is Mr Jones Nil by Mouth (NBM) and why is it important to maintain a strict fluid balance
The surgeon arrives to review Mr Jones and after examination and review of the x-ray and ultrasound the decision is made to take Mr Jones to theatre as he has a small bowel obstruction. As yet the cause unknown.
5.Discuss 3 preoperative nursing procedures you would undertake specifically for a patient being prepared for theatre for a small bowel obstruction.
6.a)Discuss the pathophysiology related to small bowel obstruction.
b)How would you explain this to Mr Jones using language appropriate for a patient?
Please discuss what education you would provide Mr Jones with preoperatively in regards to the 3 elements below, and how this will assist with Mr Jones care postoperatively.Pain relief / Lung function / Mobilisation post theatre
When Mr Jones returns from Theatre the following is noted
Vital observations BP 100/60, HR 85bpm Resp rate 12bpm, Temp 36, O2 92%, 8/24 IVT, PCA (Morphine 1mg per ml), IDC on hourly burette measures, Wound dressing dry and intact with Bellovac x 1 on free drainage, IVABs, check XR and Hb in am, Sequential Compression Device (SCD)
8.List 7 important pieces of information you would require when receiving the handover from the theatre nurse.
9.Outline two (2) nursing interventions you would undertake for each of the following four (4) items below that will assist in the prevention of post-operative complications for Mr Jones in the first 24- 48 hours post theatre recovery.
a.Pressure area care
b.Lung function
c.Range of motion
d.Psychological support
After settling Mr Jones into his room, on the second set of observations he starts complaining of severe pain at the wound site.
HLTENN011 Implement & Monitor Care For A Person With Acute Health Problems.
10.Identify four (4) non-verbal signs that Mr Jones may exhibit when experiencing unrelieved pain.
Mr Jones’ condition and Level of consciousness (LOC) starts to deteriorate. When you arrive to complete another set of observations you are concerned that he appears drowsy and has trouble responding to verbal stimuli.
11.Identify a minimum of two (2) nursing interventions you would perform at this point.
Mr Jones continues to deterioration rapidly. Heart rate 45bpm, respiratory rate is 8bpm with oxygen saturation decreased to 83%.
12.Identify a minimum of two (2) nursing interventions you would perform at this point.
Mr Jones is now in full respiratory and cardiac arrest, he is attended to by the medical emergency team and revived
13.Please describe your role in an emergency as the EN assigned to this patient.
HLTENN011 Implement & Monitor Care For A Person With Acute Health Problems.
Also, state who are the other routine members of the emergency response team.
14.Please state one of the first line drugs you may be asked to prepare for this emergency situation.
15.Please provide an example of what you would state in the progress notes following this incident
You have had 5 days off. On your return, you are assigned to care for Mr Jones again. You are handed over the following:
- Mr Jones has recovered from cardiac arrest
- He is awake and alert
- He was returned to theatre three days ago for further bowel surgery resulting in the creation of an ileostomy
- He remains NBM and has been NBM for the last six (6) days
- The doctor has written up orders to commence Parenteral nutrition
- His observations are stable and within normal limits for Mr Jones
Mr Jones’ wife has been by his side for the last 48 hours.
16.a.What steps do you need to take in setting up for commencement of parenteral nutrition?
b.State four (4) aspects of nursing care that are required when caring for a patient with a PICC line.
17.What education would you provide to the patient and his wife regarding the need for this treatment?
HLTENN011 Implement & Monitor Care For A Person With Acute Health Problems.
Part B General Questions – please answer the following
18.Match the acute conditions listed with the correct cause (please note that most of these conditions will have more than one cause)
HLTENN011 Implement & Monitor Care For A Person With Acute Health Problems.
19.What are four (4) basic principles of Surgical Nursing that you as the EN need to practice?
20.Demonstrate your knowledge of the following surgical procedures by providing a brief description and example for each.
HLTENN011 Implement & Monitor Care For A Person With Acute Health Problems.
21.a.When performing Tracheostomy suctioning / clearing of airways for a patient why is it important to allow for time between suctions if more than one is needed?
b.State three (3) nursing considerations you would perform in regards to the Chest drain insertion site (must be checked for a patient with the Underwater seal drainage system).
c.State two (2) nursing considerations for the start of your shift with a patient who has an Intercostal catheter.
d.Briefly discuss complications that may arise from the following if you are not monitoring the nursing care correctly.
CPAP, BIPAP, PICC line
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