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NCP106 Nursing care plans – Assessment 1 Part B Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Page 1 Introduction Within the health care system, Enrolled Nurses (ENs) work as part of a collaborative, multidisciplinary health care team. An essential role of the EN is to ensure that the individual health care needs of their clients are identified, and a plan of holistic care is established early on during the admission process. The client’s individual needs should be reassessed frequently, to mitigate the risk of adverse outcomes and evaluate treatments, for as long as they need care. Accurately assessing the physical, mental and emotional health status of your client can prevent adverse outcomes occurring, and can assist to identify any specific individual needs that will impact their admission. This assessment provides an opportunity to demonstrate how knowledge of a client’s health status and individual needs can ensure their treatment is appropriate, holistic and that person-centred care is provided. Summary Assessment 1, Part B, will require you to answer a number of short answer questions, amend the nursing care plan you completed previously in Assessment 1 Part A, and complete clinical documentation. The case study is based on Mr McFarlane, who was admitted to your ward in Assessment 1: Part A. To complete Assessment 1: Part B, you will need to consider the following from the case study: • The overall health status of Mr McFarlane; • What is needed to support him to make informed decisions relating to his care; and • How to best plan and implement person centred care. In your answers, you should apply an understanding of nursing diagnosis, nursing assessments, analytical thinking and nursing intervention implementation. Utilise medical terminology where appropriate, and apply directional terms when referring to nursing interventions. Assessment 1, Part B: - CASE STUDY BRIEF Course HLT54115 Diploma of Nursing Subject Code and Title NCP106 Nursing care plans Unit(s) of Competency HLTENN004 Implement, monitor and evaluate nursing care plans Performance criteria, Knowledge evidence and Performance assessed PC: 1.1, 1.2, 2.7, 3.1, 3.3, 4.1, 4.2, 4.3, 4.4 PE: 1, 3, 4 KE: 5, 6, 7 Title of Assessment Task Assessment 1, Part B: Case Study Type of Assessment Task Short Response Length As indicated for each question Submission Due by the end of Module 5.1 (Week 9) NCP106 Nursing care plans – Assessment 1 Part B Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Page 2 Task Instructions Before attempting your assessment, please refresh your knowledge of Mr George McFarlane and his underlying health concerns by first watching the video provided in Blackboard. http://www.kaltura.com/tiny/3z0xh. To complete Assessment 1, Part B, provide your responses to the questions on the Assessment Response Template below. Your responses must be typed into the spaces provided beneath each question, and the whole document and associated charts must be submitted to Blackboard as your response to Part B. Assessment 1, Part B, should build on your responses to Assessment 1, Part A, by demonstrating your knowledge of the client’s related medical history, Nursing Care Plan recommendations and current vital signs. You should discuss rationales and analysis of nursing interventions implemented and complete all documentation on required charts which will be provided via Blackboard. These questions must be answered in full. When responding to the questions, you need to pay attention to the entire question being asked, as well as the prescribed word count. You are required to use the correct medical terminology when answering all questions and also refer to the assessment charts used. 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 the assessment. If your assessment is not deemed satisfactory, you will re-assessed as per the THINK Education Assessment Policy for Vocational Education and Training (VET) v.4 (04 June 2018), before being awarded a Non Satisfactory mark for the assessment and the unit. Submission Instructions Submissions for Assessment 1, Part B - will be open from the beginning of Module 1.1 until the due date, which is 23:55hrs AEST/AEDT Sunday of Module 5.1 (Week 9). Submit your final response via the Assessment link in the main navigation menu in the NCP106 subject page. The facilitator will provide feedback via the Grade Centre in the Blackboard portal. Feedback explaining the rationale for your grade can be viewed in My Grades. Assessment Process • All items must be submitted by the due date. • All items must be satisfactorily answered / addressed / completed in order for you to achieve a “Satisfactory” outcome for this assessment. • Please note that this is one assessment from the range of assessment tasks you will complete. You must complete all assessment tasks in this subject. Please refer to your subject outline for information on the other assessment tasks. • Clear, constructive and accurate feedback will be given to you on your results and performance. • The assessment items you submit will be retained by the college as evidence of your performance. College Policies and Procedures relating to assessments, and associated forms, are available via http://www.think.edu.au/studying-at-think/policies-and-procedures http://www.kaltura.com/tiny/3z0xh http://www.think.edu.au/studying-at-think/policies-and-procedures NCP106 Nursing care plans – Assessment 1 Part B Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Page 3 Question 1 (500 word count) On Sunday at 13:42hrs, you are about to leave to have your lunch break when Mr McFarlane’s wife calls you from the corridor and states “Nurse! My husband does not look well and something is wrong with him. Please can you come and have a look at him?” On entry to Mr McFarlane’s room, you notice the following: • His breathing is short and shallow • Pale and clammy skin with cyanosis around his lips and peripheral extremities • His eyes are closed and not opening when you call his name; they open when you apply pressure to his chest • He is confused and not making sense • His best motor response is localising • He is lying in a supine position at a 60% angle • Vital signs RR: 9, SpO2: 74% Room Air, BP: 100/60, HR: 45, Temp: 38.7 • BGL 1.9 mmol/L • GCS 12 Discuss your nursing actions and rationales for your decisions, taking into account policies and procedures and scope of practice as an Enrolled Nurse (EN). Discuss to whom you would refer the changes in Mr McFarlane’s condition. Consider, in your response, any concerns about Mr McFarlane’s current vital signs or clinical status; for example: GCS 12, BGL 1.9 mmol/L, and any relevant previous medical history. Consider the position of Mr McFarlane and how/if you could safely reposition him, considering his BMI and safety precautions / risk minimisation actions. Ensure that the vital signs observations, BGL and GCS are documented on the charts utilised in Assessment 1A and upload these updated charts as part of your assessment response. NCP106 Nursing care plans – Assessment 1 Part B Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Page 4 Response Question 1: NCP106 Nursing care plans – Assessment 1 Part B Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Page 5 Question 2 (150 - 300 words) Based on the initial handover you received for Mr McFarlane and, taking into account his recent clinical deterioration, consider how best to update the plan of care for Mr McFarlane. Use the template below to outline the anticipated care for Mr McFarlane taking into consideration his past medical history and recent events. Ensure that you remain within your EN Scope of Practice and take into account policies and procedures. This requires you to: • Outline two (2) new nursing diagnoses or risk factors associated with Mr McFarlane’s current health presentations (these nursing diagnoses or risk factors cannot be the same ones used in Assessment 1, Part A) • List and justify at least one (1) nursing intervention(s) that could be instigated for each diagnosis. • Specify at least one (1) member of the multidisciplinary team that may be able to support your suggested interventions. • Describe how your planned intervention(s) reflects the client’s interests and physical, emotional and psychosocial needs • Identify and explain at least one (1) expected outcome(s) that you would hope for as a result of each intervention. Consider in your recommendations, Mr McFarlane’s risk of DVT, VTE, unstable BGL`s, diet, current GCS score, vital signs, clinical investigations and recent clinical deterioration. Nursing diagnosis Planning and rationale - (Nursing intervention) Multidisciplinary member to provide support Link to physical, emotional and or psychosocial needs Expected Outcome NCP106 Nursing care plans – Assessment 1 Part B Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Page 6 NCP106 Nursing care plans – Assessment 1 Part B Version 1. RTO Code 0269. Think: Colleges Pty Ltd. CRICOS Provider No. 00246 Page 7 Question 3: Nursing Documentation (100 - 250 words) At the end of your shift you need to complete nursing documentation to record the care you provided to Mr McFarlane. Using