Faculty of Social and Health Sciences
Bachelor of Nursing
HEAL 5026 Introduction to Nursing Practice
Summative Assessment One:
Worksheet six : 1%
(Refs: Crisp, Taylor, Douglas & Rebeiro (2013) , and SIM lab sessions
Planning Care and Risk Assessment
Read the following patient scenarios and complete a Nursing Care Plan for each.
Include both actual and potential problems as appropriate.
You should aim to have a minimum of three problems for each.
Each scenario also asks you also to complete a different risk assessment; the Morse falls
assessment, Waterlow assessment, the Glasgow coma scale or a pain assessment.
Mrs Jones is 78 years old. She is now a resident in an aged care facility as her family decided
it was unsafe for her to be at home on her own due to her 3 falls in the last two months.
She uses a walker reluctantly and says she feels “a bit unsteady and weak” when she gets
up out of her chair and when she has a shower. Mrs Jones is breathless following a recent
case of bronchitis. She has a history of hypotension and of late she has been forgetful of
where she is. Her temperature = 38.8 C, respirations = 34 per minute, pulse = 88 beats per
minute, blood pressure = 100/60 mmHg. You assess Mrs Jone’s urine to be offensive
smelling and she tells you that it is painful when she goes to the toilet. She tells you she is
anxious about being in the hospital and sad about leaving her home.
What is Mrs Jones’ score using the Morse falls assessment?
What does this mean for Mrs Jones’ care?
Problem (actual / potential)
Problem
intervention
1.
2.
3.
goal
rationale
Explain how the nurse will evaluate this problem
Problem (actual / potential)
Problem
goal
intervention
rationale
1.
2.
3.
Explain how the nurse will evaluate this problem
Problem (actual / potential)
Problem
intervention
1.
2.
3.
goal
rationale
Explain how the nurse will evaluate this problem
Mr Appleby is 74 years old. He has a 2 cm x 2 cm decubitus ulcer on his heel (stage 2) and is
in the hospital for respite care. The decubitus ulcer limits his mobility. His medical history
shows he is a type two diabetic. Mr Appleby is a smoker, usually having 15 cigarettes per
day when at home. He has not passed a bowel motion for 4 days and is feeling “off his
food”. He says that he finds it difficult to get to the toilet on time preferring to use a bottle.
He notes that he has lost 4 kg in the last month without trying. He is 170cms tall and weighs
72 kgs. Mr Appleby’s skin is dry and bruises easily. He has 5 mosquito bites on his arms
which he scratches continuously. Two areas have broken skin. Mr Appleby is worried about
his cat Tess and who is feeding her and caring for her. He tells you he can’t sleep at night
because of this.
What is Mr Appleby’s risk for further decubitus ulcers using the Waterlow Assessment
scale?
What does that mean for Mr Appleby’s care?
Problem (actual / potential)
Problem
intervention
1.
goal
rationale
2.
3.
Explain how the nurse will evaluate this problem
Mr Jacobson is found lying on the floor of the bathroom. He appears to have hit his head
on the basin. He answers you only when he hears your voice and he is not sure where he is.
When you ask him to move his legs and squeeze your hand he responds appropriately.
His vital signs are : B/P= 135/85 mgHg, Temperature = 36.8 C, Respirations =26 beats per
minute, heart rate= 88 beats per minute. He is returned to his bed with the assistance of 3
nurses and a hoist and asks if he can just sleep. His mouth is dry, tongue is furry and his lips
are cracked. You notice he has had minimal urine output over the last couple of days. Later
Mr Jacobson tells you he has pain.
Explain how the Glasgow Coma scale assessment might be beneficial in this situation.
What was his score at the initial assessment? And how will this impact on his care?
Outline a comprehensive Pain assessment to assess Mr Jacobson’s pain.
Documentation
The nurse makes a mistake by writing about Mr Brown’s care in Mr White’s progress notes.
Explain the action the nurse needs to take
There are 8 general principles of safe and effective documentation. Identify these principles
and show your understanding of how to apply them in the clinical setting.
Computerised progress notes and patient records present further responsibilities for health
professionals. Explain two of these responsibilities.
Outline three reasons why incidents forms are completed in the clinical area.