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HLTENN003-Perform clinical assessment and contribute to planning nursing care - task 1Assessment

HLTNN003 Perform clinical assessment and contribute to planning nursing care
Assessment Task 1 – Questioning
1. Short note on different development stages of:
 Toddler (1-3 years old)
a. Physical growth: grows rapidly but dramatically slow comparing to the infant; has between eight and
twelve teeth; can listen to people talk, music and simple instructions
b. Psychosocial growth: imitates others’ behaviour; distinguishes themselves from others; builds up
company to other children
c. Cognitive development: Says a few words then talks a lot; acknowledges first and last names; can
sing; builds up approximately 300 vocabularies; points out familiar objects or parts of the body;
expresses toilet needs
d. Motor development:
- Gross motor: Walks alone; begins to run; walks down and up stairs; jumps; kicks a ball; stands
on tiptoe
- Fine motor: Feeds self with cup and spoon; push toys together; holds and begins using crayons;
learns to use scissors
 Preschool child (3-6 years old)
a. Physical growth: steadily growing and gaining weight; gets taller and becomes losing some fat.
b. Psychosocial growth: is increasing sociable with other children and adults than parent; slowly
becomes independent;
c. Cognitive development: language skills are well developed; is able to understand and speak clearly;
talks and asks questions such as why, how; builds more than 2000 words; identifies colours; actively
d. Motor development:
- Gross motor: rides a bike with training wheels; throws a ball; balances on one foot; most skips
hops on one foot; climbs
- Fine motor: uses scissor; draws simple things such as circle, square; learns to tie and buckle
shoes; brushes teeth and washes face; draws six-part person; dresses independently; buttons
 School aged child (6-12 years old)
Physical growth: gains on average 6cm of height and 3 kilograms of weight per year; the growth has
slower and faster periods; girls are higher, heavier and normally look more mature than boys
(Brunik, 2014)
Psychosocial growth: tries to be a part of a peer group; learns to achieve variety skills under others’
approvals; evaluates self by their action and interactions with others
Cognitive development: is able to understand others’ perspectives; becomes thinking more logical
and rational; increases vocabulary; can react properly, predict situations and find solutions faster.
Motor development:
- Gross motor: can ride a skate board or rip stich; can ride bicycle with two-wheels; plays netball,
- Fine motor: can put models together; likes doing crafts; plays board games and cards
2. Physical growth and development of an infant (0-12months): dramatically and rapidly physical growth
during infancy. Many babies cry a lot in evening when they are under three months and easily are
HLTNN003 Perform clinical assessment and contribute to planning nursing care
stimulated by external factors such as shape, colours and sounds. By four months babies grow about 3
inches in height and gain an average of 4.5 pounds in weight. Their head circumference also grows per
month during infancy. By six months, babies have doubled weights from birth, and gained day by day.
From six months, growth may begin to slow. Babies have grown about 10 inches in length and their
weight has tripled from birth. Some babies can start teething at this age.
3. The importance of Play in a child’s development: Play contributes to children’s physical, cognitive,
social and motional developments. It also gives the chances for parents and others to engage with
children. Through playing children can explore themselves and the world and gain needed skills to face
future challenges. It is important for developing brain function when children can learn, imagine,
practice skills, express their emotions and interact with others. Moreover, play helps children build up
their physical growth in muscle tones and bones development.
4. 4 impacts that a family may have if a child gets hospitalized:
Accommodation for family
5. The development stages of adolescence (12-18 years): Children develop personal identities and transfer
from childhood to adulthood in adolescent period. Physical and sexual maturity will be achieved during
the period, and girls tend to experience puberty earlier than boys. Children also develop their
sophisticated cognitive and interpersonal skills. They will identify their roles, behavious and obtain
education and occupational opportunities for their future. Language skills are fully developed. Cognitive
and brain development are complete. Physical skills are developed well, and muscles still develop.
Children are also lack of coordination when facing the situations are rather hard to deal with. They will
gradually grow independent from parents.
4 common health issues:
Traffic injuries
6. Adulthood:
Young adulthood (18-30years): is the time for adults separate from their families and start independent
lives. They may have new commitments, responsibilities and be accountable in social, work and
personal relationships. They will explore the world more when meeting various people, situations and
values. They also face to differences in generations in their relationships with parents.
3 major activities:
Form relationships and can result in marriage or having babies
Set up and manage their own households
Make career or work choices
Early middle adulthood (30-50years): Individuals experience relative physical and mental health. Most
of them settle into careers, lifestyles, relationships and other social activities. They also achieve
maximum productivity in work and other aspects of their lives. They will concern contributing to their
HLTNN003 Perform clinical assessment and contribute to planning nursing care
next generation. They also face to responsibilities that may interrupt their lives such as chronic ills,
ageing parents.
3 major activities:
Accept and adjust to physiological changes such as menopause
Help their next generation to become responsible adults
Develop leisure time activities
Late middle adulthood (50-70 years): many individuals may suffer chronic health problems such as
cardiovascular disease, cancer, diabetes or asthma. Especially women undergo menopause at late 40s or
early 50s. There are some changes occur in work, family, social and community such as their families’
structures, being grandparents. However, individuals still maintain their choices or interest in some
aspects of their lives such as political, cultural, religious issues.
3 major activities:
Adapt to physical and mental changes and health status
Develop supportive relationships with adult children
Adjust to possibility of parents’ loss
Late adulthood (70 years to death): their physical and emotional changes will depend on how individuals
achieve their developmental tasks of middle adulthood. In this stage, individuals normally achieve
almost their goals of lives, so they are out of workplace and may have more leisure time activities.
However, their health status, family relationships, financial status also impact on the ability they cope
with the changes.
3 major activities:
Develop new roles in families because they are eldest members
Build their relationships with own age group
Adapt to loss of partner, family members and friends
7. Infertility impacts on parents:
Infertility has potentially threatened their emotions. Some individuals might suffer some negative affects
on their personal relationships and their identities. Therefore, infertility can highly impact on
psychological aspect of parents and may result in depression and anxiety.
8. 2 theories enable understanding of human growth and development:
The ages and stages of Piaget (1952), Erikson (1974) and Kohlberg (1981): The theories sated that
humans experience certain similar physical, cognitive, psychosocial and moral changes during each
developmental stage in their lives. They also gain specific physical and psychosocial skills during each
period and must achieve as those skills will be readiness for following different new developmental
tasks. Therefore, humans need appropriate environments to help achieve their developmental tasks
during their life span.
The life events or transitional theories of development: This group of theories implied that human’s
development is to response to specific life events and transitions. Following that, human must do certain
tasks such as adaptive behaviours to cope with their life events and transitions that may be positively or
negatively stressful. According to Aldwin (2009), biological status, personality, cultural orientation,
socioeconomic status, interpersonal support systems, number and intensity of life events and orientation
to life can affect the way human responds to life events. Besides, the stress from the life events also
impacts human’s physical and psychological health problems.
HLTNN003 Perform clinical assessment and contribute to planning nursing care
9. 3 influences on growth and development of:
Inherited traits or characteristics such as eye colour, hair colour
Genetic Abnormalities
Down syndrome
Environment: Nurturing environments help children learn to regulate and verbalize their emotions in a
manner appropriate to their ages.
How parents treat children influences the way they treat others within and outside of the
Children from low income homes are often underweight.
10. Health care needs of a family:
National home doctor
Supervision for medication
Assistance with personal hygiene
Emergency first aid related to certain illnesses such as diabetes, allergic reaction
11. Gender specific needs for each gender:
Birth control annual exams
Breast cancer awareness education
Heart health screening test for men
Prostate cancer consultation
12. Describe 2 equipment that are used for undertaking health assessments:
a. Scientific name: Stethoscope
b. The significance: A vital instrument in a medical process, is used for listening to the body such
as heart sounds, blood pressure, respiratory sounds
c. Image:
d. Guide to use:
Choose the quiet environment
Perform hand hygiene
Warm up the stethoscope by rubbing it or using warmer device
HLTNN003 Perform clinical assessment and contribute to planning nursing care
Place eartips in the ears and adjust them to make sure they are facing forward and fit the ears
Hold the chestpiece by your fingers and keep the thumb under the tube
Check the sounds by tapping the chestpiece gently
Apply the chestpice directly against skin with gentle pressure. Can choose diaphragm for hearing
medium- or high-pitched sounds, and the bell for hearing low-pitched sounds
After the assessments, wipe the eartips with alcowipes
e. Listen to the sounds and count the rate if it is necessary to collect and use the data from the
a. Scientific name: digital thermometer
b. The significance: a tool to assess patient’s temperature, it is quick to use and accurate
c. Image:
d. Guide to use:
Perform hand hygiene
Take the thermometer out of its holder
Put the probe cover on the tip if needed, otherwise clean the ended point of the probe tip by
rubbing alcohol or soap and warm water
Turn on the thermometer by pressing the button
Apply it to the measurement site such as oral, underarm under approximate time
Remove the thermometer when hearing the beep sounds three times
Turn off after recording data and clean the probe tip
e. When the reading is ready, the thermometer will produce the sounds. The temperature will be
displayed on the window.
13. An EN assists a person in activities of daily living:
An EN may assist a patient in personal care where following assessment under the direction and
delegation of a registered nurse. When assisting the person with the activities of daily living, EN must
observe changes in that person’s health conditions and report these to the registered nurse, administer
medicines and undertake other nursing care responsibilities. EN needs to encourage the person to help
themselves as much as possible. EN uses communication skills effectively to gather information and
educate or instruct the person to use supportive equipment and maintain personal hygiene. EN must
follow the policies and instructions when using aids to assist the person.
Examples of aids: wheelchairs, shower tools, communication aids such as hearing aids
HLTNN003 Perform clinical assessment and contribute to planning nursing care
14. Principle for health assessment:
A nurse needs to link your essential knowledge of anatomy and physiology with the measurement,
assessment and recording of the functionality of the body. The nurse will perform certain assessments
and obtain relative database of the patient. Therefore, nurse can gather and report accurate information
to doctor or others in the multidisciplinary team. Following that, nurse will be able to identify the
patient’s health care problem and provide the appropriate care plan to meet the patient’s need.
15. a. Steps to determine that a patient is deteriorating: patient can deteriorate suddenly or over the periods
of time. In order to determine the patient’s conditions, there is a need to undertake a comprehensive
assessment to assemble information.
Undertaking physiological observations including:
 Temperature
 Respiratory rate
 Heart rate
 Oxygen saturation
 Blood pressure
 Level of consciousness
During the assessments, must include thresholds for each or combination of the parameters to indicate
Documenting relative information including fluid balance, pain, skin colour, results of tests, other
neurological sign such as pupil size and reactivity.
Recording physiological observations on the evaluation chart to monitor the results
Improving the monitoring plan in frequency and nature of observations depend on the patient’s situation.
Documenting any modifications.
(Department of Health, 2014)
b. Assess level of consciousness (LOC):
LOC is assessed through observations of patient’s body position, movement, eye opening or
verbalization. Observe the patient’s eyes when entering the room. If the patient closes their eyes,
introduce yourself and observe how they response to verbal stimuli. If the patient does not respond,
gently touch or shake the patient’s hands to awake them. If the patient still does not respond, undertake
pain stimulus such as applying pressure with a pen to the nail bed. Note the patient’s responses such as
opening their eyes, observe motor responses and how the patient localise the painful part. Observe the
motor responses of right and left sides. Assess orientation by asking patient about person, place and
time. Determine the Glasgow Coma Scale score.
c. When identifying the changes in vital signs and serious adverse events, the concerns should be raised
about this patient’s deterioration. Particularly, when recognising any abnormalities of vital signs
including failure in assessment of consciousness, there is a need to communicate with other staff about
concerns. Should notify medical staff of the signs immediately to avoid any delays in responding. As an
EN, you should report these to RN or doctor.
16. The mealtime management in Nursing practice has been developed to support nurses working with
people and their families who support people with disability. It provides a guideline for nurses to
promote the best practice through obtaining nutrition for health and wellbeing, dysphagia management
HLTNN003 Perform clinical assessment and contribute to planning nursing care
and enteral nutrition of tube feeding. Nurses must acknowledge the importance of good nutrition and
understand risk factors and adverse outcomes of poor nutrition. Those things will help to underpins
health and wellbeing. Particularly, people with disability are highly potential rates of dysphagia that may
lead to death. Finally, nurses are responsible to perform best practice in enteral feeding practice to
enhance patients’ health and prevent any related infection problems.
17. Wellness approach to health on
a. Physiology: Physiological health is the most commonly indicator to assess the wellbeing of
individuals. The multiple physiological subsystems in the body have contributed to the overall health
and well-being of an individual. It can be said that healthy organs and cell functions help to prepare
the bodies to deal with illnesses. Following this point, regular exercise physiology, sleep well and
health food underpin wellness.
b. Psychosocial aspects: Psychosocial wellbeing refers to mental health of an individual when there is
an absence of mental illness. Following this point, human’s health and wellbeing will also promote
positive mental health and wellbeing by increasing emotional resilience, reducing vulnerability to
mental ill-health, and developing support environments for people who suffer psychological effects
such as depression, anxiety, decreased concentration, attention, and memory. So far, to approach
psychological wellness, health care system needs to have a look at the positive concept related to the
social and emotional wellbeing of individuals and communities.
18. 2 variations in health needs and activities of daily living for a person with a disability across his/her
Self-care, Communication
19. Using Glasgow Coma Scale (GCS) to assess the level of consciousness of a patient:
The GSC uses 3 categories including eyes opening, verbal response and motor response to assess
different areas of a patient’s consciousness. A score is applied to each category, then added up to give an
overall score ranging from 3 (deep unconscious) to 15 (normal conscious).
Eyes Open
Score Best verbal response Score Best motor response
Spontaneously 4
Obey commands
To speech
Localise pain
To pain
Flexion abnormal
Extension to pain
GSC is only uses for adult patients and practitioners need to have their clinical judgment when using it
to assess consciousness.
Assessing eyes opening response:
Spontaneous: Observe the patient’s eyes when entering the room. It is recorded when patient is awake
with eyes opening.
To speech: If the patient closes their eyes, introduce yourself or supply verbal stimulus to the patient. It
is recorder when the patient opens his or her eyes to respond.
To pain: It can be recorded if a patient opens her or his eyes to a painful stimulus such as fingertip
HLTNN003 Perform clinical assessment and contribute to planning nursing care
None: If there is no response to pain, it is recorded.
Assessing verbal response:
Oriented: Patient must be able to identify who they are; where they are and the time such as month of
Confused: If a patient is slightly confused and answered incorrectly those above questions.
Inappropriate: If a patient has inappropriate words without exchange of information during the
Incomprehensible: If a patient is making sounds but her or his words and speech cannot be identified.
None: If there is no response verbally to verbal or physical stimuli.
Assessing motor response:
Obey commands: Asking the patient to do something such as to raise her or his eyebrows, to hold and let
go your fingers. It is recorded if the patient responds and dose what you ask.
Localise pain: Using the same above techniques to produce a painful stimulus. If the patient responds to
the stimulus and remove it by pushing your hand a way, it is recorded.
Withdraw: If the patient pulls away from the stimulus that you supplied above, it is recorded.
Flexion abnormal: If the patient’s arms move toward his or her chest, fingers and wrists flex on the chest
and he or she points the toes, it is recorded.
Extension to pain: If the patient’s arms and legs straighten, the wrists rotate away from the body and
He or she points the toes, it is recorded.
None: If there is no any motor response to the painful stimulus.
20. Pupillary reaction: refers to the changes of pupil’s size to respond to variety causes such as light, other
To measure constriction or dilatation of a pupil, move a penlight from the side to the front of one eye.
Then observe the other eye for pupillary constriction.
21. Neurological reflexes:
Deep Tendon Reflexes: are used to test afferent nerves, synaptic connections within the spinal cord,
motor nerves and target muscles.
Normally DTR testes biceps, triceps, brachioradialis, patellar and Achilles.
Use a reflex hammer to stretch the tendons and muscles at identified places.
Ask the patient to contract the muscle where the tendon is attached.
Strike the tendon with a single, brisk, stroke.
DTR are often rated according to the following scale:
0: absent reflex
1+: hypoactive
2+: normal
3+: hyperactive without clonus
4+: hyperactive with clonus
Clonus: includes rhythmic, rapid alternation of muscle contraction and relaxation caused by sudden,
passive tendon stretching. It is used to test for an upper motor neuron disorder.
If DTRs are hyperactive, test for ankle clonus. Ask the patients to relax and support their knees in a
partly flexed position. Dorsiflex the foot and observe for rhythmic clonic movements.
HLTNN003 Perform clinical assessment and contribute to planning nursing care
Babinski reflex: This reflex is mediated by the spinal cord but influenced by higher centers. It is used to
indicate loss of cortical inhibition.
Stroke the lateral aspect of the sole of each foot beginning from the heel, moving forward toward the
small toe, then come across foot medially toward the big toe with a sharp object.
The normal response is downward contraction of the toes. The abnormal response is characterized by an
upgoing big toe and fanning outward of the other toes.
Abdominal Reflexes: Those reflexes can be used to test the central nervous system lesion. It is said that
the loss of abdominal reflexes tends to occur late in motor neuron disease.
Lie down the patients relaxing with their arms by their side. Stroke the abdomen lightly on each side in
an inward direction above and below the umbilicus with a key or tongue blade. Note the contraction of
the abdominal muscles and deviation of the umbilicus towards the stimulus.
22. A person centered approach: meant there is a needs to place the person with disability at the centre of
decision making when provide them supports and services. In a person centred system, the rights of
people with disability, and their families and carers to make choices about their own lives are respected.
A person with disability, their families and carers are heard and supported to exercise choice and to
direct supports and service arrangements.
(FASC, 2012)
It is necessary for nurse to develop a health assessment because health assessment is the first step in the
process of determining the person’s health care needs. It provides significant information to develop the
plan of action that enhances personal health status. It helps nurses and other health care professionals
can establish baseline data and the person’s current health condition before providing care.
Therefore, when working with the person with a disability and their family, nurses must encourage them
to involve in the development of a person’s health assessment and in negotiating goals and generating
and implementing relevant information required. This Health assessment is a systematic approach to
gathering health-related data. An assessment is used for:
• screening and diagnosis
• the documentation of baseline data
• the rationale for therapeutic interventions
• the foundation for health care planning
• the evaluation of therapeutic interventions
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HLTNN003 Perform clinical assessment and contribute to planning nursing care
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Australian and New Zealand 2nd Edit
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