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NURS11160 Fundamentals of Clinical Nursing T1 2019

Assignment Two - Written Assessment

Assessment Item Two addresses unit learning outcomes one and three.

1. Apply the principles from the nursing process to deliver evidenced based, person centred nursing care to individuals and families at novice level.

3. Relate the significance of the Nursing Midwifery Board of Australia (NMBA) standards for practice and specific National Safety and Quality Health Service Standards (2nd edition) to nursing.

   practice.

Details : The following written assignment is based on a scenario of Mrs Maude Manser. The video’s of the scenario are available on the Moodle site and are called ‘Maude Manser and you as a first year nursing student’. (The video is presented in 3 parts specific to your assignment). You cannot complete this assignment without referring to the videos.

In preparation for the assignment, you will need to download the following documents:

· Fluid balance chart

· QADD’s vital signs chart

· Nursing progress notes.

These are available in the assignment section on the Moodle site. You are then to read the assignment task set out below and watch the videos. This assignment has a focus on patient assessment, fluid balance charts, vital signs and professional communication.

Each of these are linked to a number of the National Safety and Quality Health Service Standards ([NSQHS Standards] 2nd edition) and align with unit learning outcomes. The relevant standards should be considered when developing your discussion.

Setting the scene for your assignment

You are a first year nursing student on your first clinical placement. You are on the Medical ward at CQUniversity Hospital. It is the morning shift and you have been assigned the responsibility of looking after Mrs Maude Manser under the supervision of the Registered Nurse.

Who is Maude?

The following are Maude’s demographic details taken from her patient charts. This is important information that you will need when completing patient charts for your assignment.

Name: Mrs Maude Manser (prefers to be called Maude)

DOB: 12.09.1941

Address: 53 Serene Crescent, Douglas

Weight 75kg

Height: 163cm

ISBAR clinical handover for shift change

It is 0700hrs and you have just started your shift. Clinical handover has begun. You receive the following information at Maude’s bedside from the nurse who is about to go off duty. The nurse refers to Maude’s care plan in delivering the information to you.

Situation: Mrs Maude Manser was admitted to medical ward from the Emergency Department with generalised abdominal distension, nausea, loss of appetite and a pain score of 5/10. Maude is unsure when she last had her bowels opened as they have been irregular of late.

Background: Mrs Manser has a history of congestive cardiac failure, generalised pain from osteoarthritis, vision impairment and hypotension. In 2010 Mrs Manser underwent successful surgery to replace her right knee joint. Over the course of 2019 her left knee pain has escalated to the point where her GP has recently prescribed stronger pain relief. This medication can cause constipation. Current medications: Furosemide 40mg PO mane, Metoprolol 190mg SR PO mane, Panadol Osteo 665mg PO TDS ceased recently and commenced on Panadeine x 2 tablets PO 4-6hrly max of 8 tablets per day. Mrs Manser lives with her husband Tom. Mrs Manser sees family regularly, volunteers for meals on wheels and visits the local nursing home.

Assessment: Mrs Manser is usually independent but with the onset of this pain, she reports feeling a little unsteady and reluctant to mobilise. She requires one-person assistance with standing and assistance with activities of daily living. Mrs Manser is at an increased risk for pressure injuries and falls. She is currently scoring 1 on her QADDS chart due to a heart rate of 102bpm. Mrs Manser is complaining of abdominal pain, rating it as 5/10.

Recommendations: Standard precautions are in place. Maude is currently on a full diet, but is taking very little orally. Maude is on a strict fluid balance chart and we are measuring all intake and output. Maude requires vital signs observations 4/24. Maude has been commenced on aperients and can have a microlax enema if needed; the prescription of panadeine will need reviewing on rounds. She currently requires assistance with activities of daily living and is assist by one for mobilisation. She requires falls prevention and pressure injury prevention care. The medical team will review Maude this morning at 1000hrs but Notify Dr Crane if you have any concerns.

Your responsibilities in looking after Maude whilst under the supervision of the registered nurse include:

• attending to her hygiene and toileting needs;

• assisting with meals;

• mobilising Maude safely;

• pressure injury and falls prevention;

• monitoring her vital signs and

• maintaining her fluid balance chart;

• maintaining a bowel chart.

What do you need to do next?

Title page and general instructions

Create a title page for the assignment and include all relevant information including student name, number, unit name and number, assignment number and word count.

Ensure you use 12-point font and minimum double line spacing.

Please also ensure you include a contents page as the use of headings is encouraged.

The first part of your assignment

Open your assignment with an introduction then move into the required tasks as per instructions (allow 200 words).

The second part of this assignment

Prior to caring for Maude, you are conscious that you need to maintain hand hygiene.

Complete the hand hygiene package on Hand Hygiene Australia (HHA). Please click on “On-line Learning” tab. You may need to register if this is your first visit to HHA. Please search for and then complete the “Hand Hygiene Student Health Practitioners Online Learning Module.”

https://www.hha.org.au/

Once completed you will need to print off the certificate. You will need to submit this as Appendix A of your assignment.

The third part of this assignment

You are also aware, based on the clinical handover, that Maude is at risk of falls and pressure injuries.

You are to briefly explain:

· What are the risk factors that puts Maude at risk of falls injuries and pressure injuries?

· Outline a nursing management plan to prevent Maude falling and sustaining pressure injuries while she is an inpatient.

You should allow 500 words for this.

Please back up your information with quality references and provide links to the NSQHS Standards (2nd edition).

The fourth part of the assignment

Your shift progresses. You attend to Maude’s care. It is now 1130 in the morning. You are required to complete Maude’s fluid balance chart (FBC). You also check if Maude has had her bowels opened as this needs to be charted 4/24.

At 1445 you will need to go back and complete the fluid balance chart for the remainder of your shift.

Download the fluid balance chart from the Moodle site and document all input and output from 0800hrs until 1430hrs according to what Maude tells you in the video. This completed fluid balance chart will be Appendix B of your assignment.

The fifth part of the assignment

Continue watching the video. At 1155hrs you go into Maude’s room and she is sitting on the side of the bed rocking and holding her abdomen. She states to you “The pain in my tummy is quite bad and I feel nauseated.”

You then take Maude’s vital signs. It is 1200hrs and your findings are as follows.

Respiration 21

Oxygen saturation 96% on room air

Blood pressure actual: 100/60. Use the default systolic BP to determine a score for actual BP.

Pulse 100

Temperature 37.2

Conscious state – Alert

Pain score 6/10

Document the vital signs on the QADD’s chart you downloaded from the Moodle site. Include all points of identification on the chart. You are to add the score and complete the documentation on the QADD's chart. You will need to submit this as Appendix C.

In the written section of your assignment you then need to explain,

· what action should be taken based on the score you calculated, and

· what nursing action you would take in regards to Maude’s complaints of pain.

You should allow 200 words for this.

The sixth part of your assignment

Based on the above scenario you have sought the assistance of the registered nurse. It is 1230 and you are to apply ISBAR in communicating Maude’s current situation to the registered nurse.

In the written part of your paper you are to include the communication you gave under the ISBAR framework. You should allow 300 words for this.

Following ISBAR communication to the RN, the RN advises that he will administer the microlax enema, Panadol Osteo for pain and that the student nurse should promote oral fluid intake and mobilise as tolerated.

The seventh part of the assignment

Explain in the written part of your assignment:

· Information that you give to both Maude and her husband to enable healthy bowel habits (for example: diet, exercise, fluid intake).

You should allow 500 words for this part.

Please back up your information with quality references and provide links with the NSQHS Standards (2nd edition).

The Eighth part of your assignment

You are now required to enter what has occurred in the nursing progress notes. Enter the situation assuming the time is now 1500hrs and the date is Tuesday 28/11/2018. Your documentation can commence from the point of Maude advising you of her increasing pain and nausea. All events unfolding from that point should be documented on the downloaded nursing progress notes adhering to the principles of professional documentation.

You will submit this as Appendix D with your assignment.

Final Part of assignment

You should close your assignment with a conclusion

You should allow 150-200 words.

Assessment Item Three addresses unit learning outcomes one, two and three.

1. Apply the principles from the nursing process to deliver evidenced based, person centred nursing care

   to individuals and families at novice level.

2. Develop an awareness of cultural, legal and ethical principles required when interacting with

   individuals, families and other members of the multidisciplinary health care team to facilitate positive

   health outcomes.

3. Relate the significance of the Nursing Midwifery Board of Australia (NMBA) standards for practice and specific NSQHS Standards (2nd edition) to nursing practice.

The simulation assessment activity will occur on the last day of your residential school or weekly clinical learning sessions.

The skill audit is non graded as pass/fail. The skills that will be assessed include:

1. Hand hygiene
2. Taking and accurately recording vital signs including: respiration, pulse, temperature, blood pressure and pulse oxygenation.
3. Ten safety questions

This is your practical assessment and you will be observed by your lecturer within the clinical learning space who will provide feedback and your result on the day.

Students will be required to accurately obtain and record a complete set of vital signs. You will also be required to complete the correct steps of hand hygiene. A 10 question safety quiz will also be completed and marked on the day.

Assessment Item Three addresses unit learning outcomes one and two.

1. Apply the principles from the nursing process to deliver evidenced based, person centered nursing care

to individuals and families at novice level.

2. Develop an awareness of cultural, legal and ethical principles required when interacting with

individuals, families and other members of the multidisciplinary health care team to facilitate positive

This is the summative quiz relating to the content of the entire 12 week unit. This quiz is compulsory for all students. This quiz is worth 40% of the grade and will be open for students to access on Thursday of Week 13. The quiz will be open for a 24 hour period only but once you commence the quiz you will have two hours to complete it. The quiz can be done online at home or on a university campus with the expectation that students will abide by 'exam like' conditions.

Online Quiz.