Health assessment Assignment | Get Homework Help
Please read the 5 questions and rubric carefully. Thanks.
Week One – Focus: Abdominal Assessment
Shift to shift Handover
| Introduction | Kaylene McCallum is a 64-year-old female admitted under Dr. Tracy Taylor |
| Situation | Kaylene presented as an inpatient to a surgical ward 2 days ago for a right knee replacement. She has mentioned that she feels bloated with slight abdominal pain/discomfort and reports she has not had her bowels open since admission. |
| Background | Kaylene has a history of hypertension, asthma and osteoporosis. She lives alone with her dog Sam. Nil known allergies. Kaylene receives an annual zoledronic acid infusion for her osteoporosis and she takes irbesartan for blood pressure control. She uses a Seretide inhaler daily and salbutamol PRN to manage her asthma. Appendectomy at 12 years of age. |
| Assessment | Vital observations
Respiratory rate – 18 breaths per minute Oxygen saturation – 99% on room air Pulse – 90 bpm, thready and regular Blood pressure – 100/60 mmHg Temperature – 37.5°C Dressing to right knee remains dry and intact. Pain to right knee – 2/10 at rest increasing to 6/10 on ambulation/movement |
| Recommendations | Maintain comfort with positioning and medications as charted
Encourage oral hydration Encourage exercise as tolerated Consider nurse initiated laxatives and report symptoms to surgical team Change diet to high-fibre Maintain use of anti-embolism compression stockings Maintain use of nonslip footwear when ambulating |
Kaylene McCallum is a 64-year-old widow and a recently retired school teacher. She has a past history of hypertension, osteoporosis and asthma, which is usually well controlled with medication. She is normally active and enjoys swimming to keep fit and is looking forward to being able to take Sam on longer walks following her knee replacement.
Today you are lookin after Kaylene, who is two days post-surgery. She is reporting bloating, generalised abdominal pain and mentions she has not used her bowels since the operation. Your facilitator explains that Kaylene may be experiencing constipation.
| ULO2
Relate principles of anatomy, physiology, and pathophysiology to the collection and interpretation of data collected during a nursing health assessment. |
Question One
You are asked to carry out an abdominal assessment on Kaylene. Describe how you would carry out this assessment, providing rationales based on anatomy and physiology. Outline the sequencing of assessment and expected findings.
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Week Two – Focus: Respiratory Assessment
Shift to shift Handover
| Introduction | Kaylene McCallum is a 64-year-old female admitted under Dr. Tracy Taylor |
| Situation | Kaylene presented as an inpatient to the surgical Ward 4 days ago for a right knee replacement. Discharge was delayed due to constipation which is now resolved as a result of the laxatives administered – bowels well open this morning. |
| Background | Kaylene has a history of hypertension, asthma and osteoporosis. She lives alone with her dog Sam. Nil known allergies. Kaylene receives an annual zoledronic acid infusion for her osteoporosis and she takes irbesartan for blood pressure control. She uses a Seretide inhaler daily and salbutamol PRN to manage her asthma. Appendectomy at 12 years of age. |
| Assessment | Vital observations
Respiratory rate – 20 breaths per minute Oxygen saturation – 95% on room air Pulse – 105 bpm, thready and regular Blood pressure – 105/60 mmHg Temperature – 37.6°C Pain – 1/10 at rest Dressing to right knee remains dry and intact. |
| Recommendations | Remove IVC ready for discharge.
Change dressing to right knee. Contact her neighbour to arrange transport home once reviewed by surgeon. |
You have arrived for your shift and are looking after Kaylene as part of your patient allocation. A few hours into your shift you notice she has become short of breath (dyspnoeic), tachypnoeic (RR24) and has an audible respiratory wheeze.
| ULO2
Relate principles of anatomy, physiology, and pathophysiology to the collection and interpretation of data collected during a nursing health assessment. |
Question Two
Your facilitator explains that Kaylene’s symptoms indicate an asthma attack. They explain that primary assessment findings that support this include: • tachypnoea • tachycardia • use of accessory muscles & tracheal tugging • dyspnoea & unable to speak in sentences • oxygen saturation is below 95% Choose one of the above assessment findings and explain the pathophysiological changes that have resulted in this abnormal assessment finding. |
| ULO3
Differentiate normal from abnormal assessment findings. |
Week Three – Focus: Cardiac Assessment
Shift to shift Handover
| Introduction | Kaylene McCallum is a 64-year-old female admitted under Dr. Tracy Taylor |
| Situation | Kaylene presented as an inpatient to surgical Ward 5 days ago for a right knee replacement. Discharge has been delayed due to constipation and an asthma attack that are now controlled. |
| Background | Kaylene has a history of hypertension, asthma and osteoporosis. She lives alone with her dog Sam. Nil known allergies. Kaylene receives an annual zoledronic acid infusion for her osteoporosis and she takes irbesartan for blood pressure control. She uses a Seretide inhaler daily and salbutamol PRN to manage her asthma. Appendectomy at 12 years of age. |
| Assessment | Vital Observations
Respiratory rate – 16 breaths per minute Oxygen saturation – 96% on room air Pulse – 89 bpm, thready and regular Blood pressure – 105/65 mmHg Temperature – 37.5°C Dressing to right knee remains dry and intact. Pain to right knee – 2/10 at rest increasing to 5/10 on ambulation/movement |
| Recommendations | Prepare for discharge tomorrow assuming Kaylene remains stable. |
You are halfway through your busy AM shift when you undertake a set of vital observations on Kaylene. You discover her blood pressure is 92/55 mmHg and she tells you that she feels a little lightheaded.
| ULO3
Differentiate normal from abnormal assessment findings. |
Question three
Using a symptom assessment framework, state 5 (five) questions you would ask to assess the hypotensive episode. Other than blood pressure, describe 3 (three) specific assessments you would undertake and using anatomy and physiology explain why these assessments are relevant. |
| UOL5
Perform and document a comprehensive and focused assessment of an individual. |
Week Four – Focus: Central Nervous System (CNS)
Shift to shift Handover
| Introduction | Kaylene McCallum is a 64-year-old female admitted under Dr. Tracy Taylor |
| Situation | Kaylene presented as an inpatient to surgical Ward 6 days ago for a right knee replacement. Discharge has been delayed due to constipation and an asthma attack that are now controlled. Kaylene also had an episode of chest pain yesterday. Kaylene was diagnosed with angina and was treated successfully with glyceryl trinitrate (GTN). She has had recent episodes of hypotension. Yesterday afternoon Kaylene experienced a transient ischaemic attack (TIA) with slurred speech and left arm deficit/weakness.
Symptoms are now resolved. |
| Background | Kaylene has a history of hypertension, asthma and osteoporosis. She lives alone with her dog Sam. Nil known allergies. Kaylene receives an annual zoledronic acid infusion for her osteoporosis and she takes irbesartan for her blood pressure. She uses a Seretide inhaler daily and salbutamol PRN to manage her asthma. Appendectomy at 12 years of age. |
| Assessment | Vital Observations
Respiratory rate – 16 breaths per minute Oxygen saturation – 98% on room air Pulse – 86 bpm, weak and regular Blood pressure – 115/70 mmHg Temperature – 37.4°C Dressing to right knee remains dry and intact. Pain to right knee – 2/10 at rest increasing to 4/10 on ambulation/movement |
| Recommendations | Continue to monitor 1/24 vital observations including neurological observations. |
You arrived at clinical placement for an AM shift and Kaylene has been allocated as one of your patients. Your facilitator asks you to assess Kaylene to assist in the planning of her care.
| UOL1
Explain and use frameworks to assist the systematic collection of data required for comprehensive and focused health assessment. |
Question four
Formulate an assessment for Kaylene using primary/secondary survey approach and explain why this approach may be considered appropriate.
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Week Five – Focus: Musculoskeletal
| Introduction | Kaylene McCallum is a 64-year-old female admitted under Dr. Tracy Taylor |
| Situation | Kaylene presented as an inpatient to surgical Ward 7 days ago for a right knee replacement. Discharge has been delayed due to multiple complications. Kaylene was diagnosed with angina and was treated successfully with glyceryl trinitrate (GTN). |
| Background | Kaylene has a history of hypertension, asthma and osteoporosis. She lives alone with her dog Sam. Nil Known allergies. Kaylene receives an annual zoledronic acid infusion for her osteoporosis and she takes irbesartan for her blood pressure. She uses a Seretide inhaler daily and salbutamol PRN to manage her asthma. Appendectomy at 12 years of age. |
| Assessment | Vital Observations
Respiratory rate – 14 breaths per minute Oxygen saturation – 99% on room air Pulse – 78 bpm, weak and regular Blood pressure – 110/75 mmHg Temperature – 37.7°C Dressing to right knee remains dry and intact. Pain to right knee – 1/10 at rest increasing to 2/10 on ambulation/movement |
| Recommendations | Arrange for outpatient cardiology review |
You arrived at clinical placement for an AM shift and Kaylene has been allocated as one of your patients. You have been assisting Kaylene with bed exercises as she recovers from her post-operative complications. Today you are required to assess her mobility status and her readiness to ambulate.
| UOL1
Explain and use frameworks to assist the systematic collection of data required for comprehensive and focused health assessment. |
Question five
Identify the indications for a mobility assessment and the specific mobility assessment tool you would utilise. Explain how you would undertake a mobility assessment on Kaylene, prior to ambulation.
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| ULO2
Relate principles of anatomy, physiology, and pathophysiology to the collection and interpretation of data collected during a nursing health assessment. |
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| ULO3
Differentiate normal from abnormal assessment findings. |
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| ULO4
Apply clinical decision making skills to synthesise data and identify patient problems. |
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| UOL5
Perform and document a comprehensive and focused assessment of an individual. |
Instructions for this assessment task:
- Assignment is to be presented with the full text of each of the five questions as subheadings
- High-quality references (unit text, other relevant texts, peer-reviewed journal articles) are to be used in supporting your responses with a focus of quality over quantity
- You should aim to include references that are up-to-date and relevant to the details in the case study and questions.
- Writing should be in the third person
- APA 6 referencing required
- Do not include an introduction or conclusion
Presentation requirements:
Font:
12-point type size.
Times or Times New Roman.
Spacing:
Double-line spacing (Do not insert extra lines between paragraphs or the references list entries.)
Page numbers
Page numbers to be provided on all pages except front/cover page. Place page number in the top right-hand corner
Margins
2.54 cm at the top, bottom, left-hand, and right-hand sides of the page.
Paragraph indents
Indent the first line of each paragraph (using the tab key or paragraph tool).
Exceptions: titles and headings
Justification of text
All text needs to be aligned to the left, not justified
Word Count
1500 words (+ or – 10%). Assignments must be no more than 10% of the indicated word count, not including title page, in-text citations, headings and reference lists.
| Criterion mode: Weight | High Distinction | Distinction | Credit | Pass | Fail | ||||||
| Starting % | 80 | Starting % | 70 | Starting % | 60 | Starting % | 50 | Starting % | 0 | ||
| Criterion 1
The student demonstrates the ability to describe the assessment in the context of the case study using knowledge of anatomy, physiology and pathophysiology. (ULO2) |
The student has:
Accurately (clearly and concisely) described the assessment and provided rationales based upon principles of anatomy, physiology and pathophysiology to justify planned assessments.
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The student has:
Clearly, but not concisely described the assessment and provided rationales based upon principles of anatomy, physiology and pathophysiology to justify planned assessments.
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The student has:
Described the assessment and provided rationales that are correct, and refer to concepts of anatomy, physiology and pathophysiology, but lack clarity.
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The student has:
Described the assessment and provided rationales that are correct, but are inadequately supported by principles of anatomy, physiology and pathophysiology.
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The student has:
Not correctly described the assessment and/or provided rationales that are incorrect, or absent.
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| Points | 15 | ||||||||||
| Criterion 2
The student demonstrates an understanding of ONE pathophysiological change related to the case study (asthma) and the associated assessment findings. (ULO 2 & 3) |
The student has:
Accurately (clearly and concisely) explained the expected assessment finding using principles of anatomy, physiology and pathophysiology.
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The student has:
Clearly, but not concisely explained the expected assessment finding using principles of anatomy, physiology and pathophysiology. |
The student has:
Correctly but not clearly explained the expected assessment finding using principles of anatomy, physiology and pathophysiology.
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The student has:
Provided some rationales for the assessment finding that are correct, but are inadequately supported by principles of anatomy, physiology and pathophysiology.
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The student has:
Provided rationales that are incorrect, or absent.
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| Points | 15 | ||||||||||
| Criterion 3
The student demonstrates the use of a symptom assessment framework and how current assessment findings can be used to plan further assessments within the registered nurses’ scope of practice. (ULO 3 & 5) |
The student has:
Accurately used a symptom assessment framework and planned further assessments, and |
The student has:
Clearly but not concisely used a symptom assessment framework and planned further assessments, and |
The student has:
Correctly used a symptom assessment framework and identified some relevant further assessments. The |
The student has:
Correctly used a symptom assessment framework and identified some relevant further assessments, but has |
The student has:
Described assessments (subjective and objective) that are not relevant, entirely outside of the |
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| Points | 15 | identified the
purpose
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identified the
purpose
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stated purpose for each assessment is correct but lacks clarity.
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included assessments that are outside of a nurses’ scope of practice (eg imaging, diagnostics). The stated purpose of each assessment is incorrect or absent.
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registered nurses scope of practice, or, has not provided further assessments.
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| Criterion 4
The student demonstrates the use of primary and secondary survey to plan and prioritise further assessments in relation to the case study. (ULO 1) |
The student has:
Accurately used the primary/secondary survey to plan and prioritise further assessments |
The student has:
Clearly but not concisely used the primary/secondary survey to plan and prioritise further assessments |
The student has:
Correctly used the primary/secondary survey to plan further assessments, but may not have identified the correct assessment priorities |
The student has:
Correctly used the primary/secondary survey to plan some further assessments, with minimal evidence of prioritisation |
The student has:
Not correctly used the primary/secondary survey or has not identified any priority assessments |
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| Points | 15 | |||||
| Criterion 5
The student demonstrates an understanding of the indications and use of a mobility assessment tool and describes how to perform the assessment. (ULO 1, 2, 3, 4 & 5) |
The student has:
Accurately (clearly and concisely) described the indications and use of the tool and how to perform the assessment.
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The student has:
Clearly, but not concisely described the indications and use of the tool and how to perform the assessment.
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The student has:
Described the indications and use of the tool and how to perform the assessment, but the descriptions lack clarity.
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The student has:
Described parts of the indications, use of the tool and how to perform the assessment, but the descriptions are incomplete |
The student has:
Not correctly described the indications and use of the tool and how to perform the assessment, but the descriptions lack clarity |
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| Points | 15 | |||||
| Criterion 6
The student demonstrates the ability to use APA referencing standards.
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The student’s work is:
Consistent with APA referencing standards |
The student’s work contains:
Several minor errors in referencing
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The student’s work contains:
Consistent referencing errors
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The student’s work contains:
Referencing errors that detract from readability at times
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The student’s work contains:
No references or citations |
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| Points | 5 |
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| Criterion 7
The student demonstrates the ability to present and structure the assignment according to the provided instructions. |
The student has:
Presented their work completely according to the provided instructions
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The student has:
Presented their work according to the provided instructions, with the exception of one or two minor discrepancies
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The student has:
Presented their work according to the provided instructions, with the exception of several minor discrepancies
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The student has:
Presented their work according to some of the instructions
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The student has:
Not presented their work according to instructions |
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| Points | 5 | |||||
| Criterion 8
The student demonstrates the ability to write in accordance with standard language conventions and academic writing
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The student has:
Written at a high level of clarity and fluency, and the work is virtually error-free
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The student has:
Written fluently but has several minor errors eg. spelling, long sentences
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The student has:
Writing that contains regularly occurring grammatical, structural errors affecting fluency
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The student has:
Writing that has errors (grammar, punctuation, sentence/paragraph structure that detract from readability at times
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The student has:
Writing that contains multiple errors in spelling/grammar and/or punctuation that significantly detracts from readability throughout |
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| Points | 5 | |||||
| Total Points | 90 | |||||
