HLTENN003 Perform clinical assessment and contribute to planning nursing care

Unit code, name and release number
HLTENN003 Perform clinical assessment and contribute to planning nursing care (2)
Qualification/Course code, name and release number
HLT54115 Diploma of Nursing (1)
Student details
Student number
Student name
Assessment Declaration
• This assessment is my original work and no part of it has been copied from any other source except where due acknowledgement is made.
• No part of this assessment has been written for me by any other person except where such collaboration has been authorised by the assessor concerned.
• I understand that plagiarism is the presentation of the work, idea or creation of another person as though it is your own. Plagiarism occurs when the origin of the material used is not appropriately cited. No part of this assessment is plagiarised.
Student signature and date

Version:
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The contents in this document is copyright © TAFE NSW 2019, and should not be reproduced without the permission of the TAFE NSW. Information contained in this document is correct at time of printing: 21 October 2020. For current information please refer to our website or your teacher as appropriate.

Assessment instructions
Table 1 Assessment instructions
Assessment details Instructions
Assessment overview The objective of this assessment is to assess your knowledge as would be required to perform preliminary and ongoing physical health assessments of all body systems, gathering data that contributes to a person’s individualised health care plan.
This unit applies to enrolled nursing work carried out in consultation and collaboration with registered nurses, and under supervisory arrangements aligned to the Nursing and Midwifery Board of Australia regulatory authority legislative requirements.
The skills in this unit must be applied in accordance with Commonwealth and State/Territory legislation, Australian/New Zealand standards and industry codes of practice.
Assessment Event number 2 of 4
Instructions for this assessment This is a project-based assessment and will be conducted as a take home assessment. You should use your reference text and learning notes when completing this assessment.
This document is in two (2) parts:
1. Research-based Project
2. Assessment Feedback
Submission instructions On completion of this assessment, you are required to upload it or hand it to your assessor for marking.
Ensure you have written your name at the bottom of each page of this assessment.
It is important that you keep a copy of all electronic and hardcopy assessments submitted to TAFE and complete the assessment declaration when submitting the assessment.
What do I need to do to achieve a satisfactory result? To achieve a satisfactory result for this assessment all questions must be answered correctly.
If you do not achieve 100% you will be provided with feedback and asked to resubmit responses to those questions you answered incorrectly within two weeks, unless otherwise agreed with the Head Teacher where there are extenuating circumstances.
What do I need to provide? Computer and/or pens and paper, internet access if submitting assessment online, ability to print or email completed assessment, learning notes, student ID.
What the assessor will provide? Printed copy of assessment, organisational policy, assessment guidance and feedback, prescribed text:
Koutoukidis, G, Stainton, K. & Hughson, J. (2017) Tabbner’s Nursing Care (7th ed.) Elsevier, Chatswood (e-textbook)
Due date Teacher/Assessor to complete as per assessment schedule
Time allowed 9 hours
Assessment feedback, review or appeals Appeals are addressed in accordance with Every Students Guide to Assessment.
Specific task instructions
The instructions and the criteria in the tasks and activities below will be used by the assessor to determine if you have satisfactorily completed this assessment event. Use these instructions as a guide to ensure you demonstrate the required knowledge.

Part 1: Research-based project
Using the templates provided in this document, answer the following questions. You are required to research from the textbook and resources provided and also using research articles from different databases.
The word limit for each answer is indicated with the question.
Once completed you will need to submit this assessment to your assessor for marking.
Brief:
1. Complete the following growth and development table based on the age and gender group stated for each person. Your answer should be a minimum of 120 words but no longer than 200 words for each person’s growth and development table.

Research and findings:
Table 2 Development Table
Person Physical Growth Psychosocial Development Cognitive Development Motor Skills Development
Suggested points to consider Height, weight, head circumference Development related to social factors, individual thought and behaviour Information processing, language learning Gross or fine motor skills
Jake
(11 months old boy) Head circumference: 44-49cm. Weight should be around 8-11kgs at this point and height should be around 70-80cm.
Amelia
(24 months old girl) Head circumference: 44-50cm. weight should be around 9-15kgs by now and height should be 80-93cm.
Ella
(pre-school age) Weight by this age is around 12-22kgs and height is usually between 92-110cm.
Matilda
(school aged girl) Weight for an average 5 year old girl should average between 14-25kgs and weight should be around 99-117cm tall.
Hamish
(15 years/ adolescent boy) The average weight for this male age group is around 40-83kgs and height 155-185cm.
Barry
(59 years old male)
William
(81 years old male)
Brief:
2. Discuss the importance of play in a child’s development.
Your answer should be a minimum of 150 words but no longer than 225 words.
Research and findings:
When your child plays, they learn about them self and their surroundings. This includes how to coordinate their body movements, talk with friends, apply rules, and more. But the learning process is even broader than this.
Play is a way for your child to familiarize themselves with the world while exploring and testing their own limits. At the same time, they are engaged in an activity that provides them enjoyment or amusement. Play helps them learn about things such as the earthworm they find on the ground, how to avoid arguments with others, their favourite make believe character during role play or that mom does not like when they yell inside the house. Promoting playtime helps your child learn about their skills and abilities, while interacting with others and their surroundings.
Play begins early. When baby studies and interacts with the things around them, whether this is by putting a toy in their mouth or touching a new textured object, they are “playing.” Part of exploring their environment also includes figuring out how to get your attention such as when baby coos or babbles at you. It is important to remember playtime helps baby to continuously master and reinforce concepts that become important milestones.
Your child will continue to play throughout childhood and you may be surprised at the number of skills they develop such as:
• Learning to exercise problem solving skills
• Showing an ability to think flexibly
• Practicing processing their emotions
• Facing their fears
• Trying new things without fear of mistake
Older children also gain something additional while they play—they discover their own interests and passions. Your child may find they have a love for a specific activity such as art or acting, or possibly for an animal or character. Playtime will encourage them to continue exploring their own interests and build skills they will use in the future.
All children should have time for play. It is the building blocks for establishing confidence, coping abilities, flexibility and positive interactions with others. Through play, your child will be able to apply these skills as they grow into a young adult.
(Bell, 2020)
Brief:
3. What are some of the common health issues Hamish, a 15 year old adolescent boy, may experience? Please list any five. Your answer should be a minimum of 20 words but no longer than 50 words.
Research and findings:
Hamish could possibly experience depression due to stress or family issues, malnutrition from not eating enough, violence either with friends or family, underage drinking and could possibly contract HIV/AIDS from sexual activity. (Organisation, 2018)
Brief:
4. A four year-old girl has been admitted to the hospital for a fractured femur.
a) Discuss the impact of hospitalisation on her and her family including her mum, dad and school aged brother.
b) Describe four strategies you might use to support Ella considering the emotional and physical needs of the family.
Your answer should be a minimum of 100 words but no longer than 150 words.
Research and findings:

Brief:
5. Jason and Sophie have been married for almost 10 years. They have tried for a long time to have a family but they are infertile. Describe the impact of infertility on Jason and Sophie. Your answer should be a minimum of 100 words but no longer than 150 words.
Research and findings:

Brief:
6. Complete the table by outlining each theory of development and the specific stage that applies to each individual listed. Your answers should be a minimum of 40 words but no longer than 75 words for each theory and a minimum of 125 words but no longer than 250 words in total for each individual.
Research and findings:
Erickson Freud Piaget Gesell
Theory outline
Jake
11 month old boy
Amelia
2 year old girl
Ella
4 year old girl
Matilda
7-year-old girl
Hamish
15-year-old male
Luke
27-year-old male
Barry
59-year-old male
William
81-year-old male
Brief:
7. Describe the influence genetics and environment have on the development of an individual. Give two examples of genetic influences and two examples of environmental influences that may affect the development of an infant 0-10 years old (Nature vs Nurture). Your answer should be a minimum of 100 words but no longer than 150 words.
Research and findings:

Brief:
8. Complete the following table identifying the health care needs of each person, considering their age and gender. Your answer for each person should be a minimum of 10 words but no longer than 50 words. An example has been provided as a guide to what is expected.
Research and findings:
Person Health Care Needs
51-year-old female Breast cancer check, cervical screening tests, pregnancy checks, immunisation checks, other health checks (Blood Pressure (BP), Blood tests), medication assistance, also if person requires any assistance at home (meal assistance/ housekeeping etc.)
William
(81-year-old male)
Helen
(63-year-old female)
Jason
(40-year-old male)
Amelia
(24 month old girl)
Brief:
9. Cath, a 53 year old female, has been admitted to the emergency ward. You are asked to collect health information and conduct a health assessment on her. Please answer the following questions in relation to Cath.
a) What is the aim of conducting a health assessment on Cath?
b) Identify the principles of a health assessment.
c) What considerations do you need to be aware of before, during and after collecting data from Cath?
d) How will you collect data from Cath?
e) List the assessments that you would do for Cath.
Your answer should be a minimum of 200 words but no longer than 250 words in total.
Research and findings:

Brief:
10. When conducting a health assessment on Barry, a 59-year-old male, and Jake, an 11 month-old boy, what are two problems you may encounter and what are some potential solutions for these problems?
Your answer for each person should be a minimum of 30 words but no longer than 50 words.
Person Problems you may encounter Potential solutions to address them
Barry
Jake

Brief:
11. Define the 6 components of health, including the physiological and psychosocial aspects of health.
Your answer should be a minimum of 350 words but no longer than 450 words.
Research and findings:

Brief:
12. Complete the following table listing the developmental stages for both adolescence and adulthood, along with the health risks and major activities related to each stage. Your answer for each person should be a minimum of 30 words but no longer than 50 words.
Research and findings:
Developmental Stages Health Risks Major Activities
Hamish
(15 year old male) Student does not need to complete for Hamish
Ashleigh
(37 year female)
Steve
(54 year old male)
Brief:
13. Complete a progress note entry for the following patient.
Your answer should be a minimum of 150 words but no longer than 175 words.
It is Monday May 6th, 2018 at 1530. You are working on the surgical ward at Lingard Hospital. Barry Smith to the unit with a fracture of left neck of femur and due for surgery under Dr Jones. He has medical history of GORD and denies any mental health history. He lives with his partner, Michael in a single storey house. He has brought his reading glasses, wrist watch and has his mobile phone and wallet in his pocket.
You take Barry to his room and discuss ward layout including the patient kitchen, buzzers, nursing station and state that the hospital is a smoke free site. You check his ID, apply his armbands and discuss the ward routine including patient rights and responsibilities, introduce staff, handover, care boards, rounding, meal times and visiting hours. You give Michael a direct phone number to Barry’s bedspace.
You conduct an admission assessment on Barry, his observations are as follows: T36.5, P86, BP 128/88, RR 16, GCS 15, pain 0/10, weight 110kg, Ht 195cm. From the risk assessment tools Barry has no identified falls risks and low risk of pressure injury. Mr. Smith is nil by mouth and has Intravenous cannula in left hand dated and intravenous therapy in progress at 125mL/hour. He has theatre attire in place; pre-operative checklist is completed and is ready for theatre.
Research and findings:

Brief:
14. Complete the discharge progress notes for Mr Smith.
Your answer should be a minimum of 120 words but no longer than 150 words.
It is Thursday May 9th. On the morning round Dr Jones informs Barry he is ready for discharge after his 3 day unremarkable hospital stay Dr Jones gives Barry a discharge letter and a script for ongoing analgesia. At 0800, you conduct Barry’s observations: T 36.2 P 82, BP 124/80, RR 18, sp02 98% RA, pain 2/10, BGL 4.2mmol/L, you remove his peripheral cannula and give him his take home medication. Barry calls Michael on 0416723411 and tells him he will be ready for discharge at 1100 however, Michael will not be able to pick Barry up until 1600 hours. Barry has had a physio consult for use of crutches and has a plan for ongoing private physio. For discharge, you liaise with the community nurse in his local area regarding wound care on left femur site. He currently has a non-adhesive island opposite to his left femur with some blood visible on the dressing. Post op notes state the staples are to stay in place for 10 days.
Research and findings:

Brief:
15. Mr William Smith, 81 years old, was admitted in the ward with confusion and agitation. After you commenced the shift at 0700 hours, you noticed that Mr Smith was not responding to your verbal command, only to pain stimuli.
a) How will you recognise if Mr Smith is deteriorating?
b) How would you determine Mr Smith’s level of consciousness? Is there any particular tool that you might use to check his level of consciousness?
c) How and when will you raise your concern for Mr Smith?
Your answer should be a minimum of 10 words but no longer than 50 words for each question.
Research and findings:
Bibliography:
It is recommended that you use either the Harvard reference style or the APA style.

Part 2: Assessment Feedback
NOTE: This section must have the assessor signature and student signature to complete the feedback.
Assessment outcome
? Satisfactory
? Unsatisfactory
Assessor feedback
? Was the assessment event successfully completed?
? If no, was the resubmission/re-assessment successfully completed?
? Was reasonable adjustment in place for this assessment event?
If yes, ensure it is detailed on the assessment document.
Comments:
Assessor name, signature and date
Student acknowledgement of assessment outcome
Would you like to make any comments about this assessment?
Student name, signature and date
NOTE: Make sure you have written your name at the bottom of each page of your submission before attaching the cover sheet and submitting to your assessor for marking.