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HLTEN51612 DIPLOMA OF NURSING
HLTEN515B Implement and monitor nursing care for older clients
Assessment B Scenarios (40%)

You must answer the questions for all 3 scenarios
SCENARIO 1
Mrs. West is a 79- year old widowed female admitted to your rehabilitation ward.
Past Medical History:
Hypertension
DM Type II – Oral Medication
Anxiety
Osteoarthritis
The nursing handover states: Right hip fracture and internal fixation. Her wound is healed.
Nutrition: If items are in reach Mrs. West is self-sufficient .She only consumes 50% of her food at each meal. She weighs 48kg and is 170cm
Hygiene: Requires assistance to dry between toes (Diabetic) but can in general manage once set up
Mobility: She requires help to get her legs out of bed and to put stockings on. Can use a pick up tool / extension arm to put slippers on, if they are in reach.
She is admitted with the main goal of increasing her mobility prior to returning home. She is not yet safe enough to step up and down a pavement or door step
Social: Normally lives alone. Her daughter lives close by and visits frequently.
The following day the progress notes read.
Refused to sit out of bed “I just don’t want to get out of bed yet”.
Mary refuses analgesia, “it’s too much trouble for those little girls, they are busy.”
She is usually continent of urine but has occasionally been found to be wet when staff have changed her position. Mary is noted to have a 1.0 CM X 2.0 cm non-blancheable reddened area on coccyx.
Physio reports that when she allows nurses to get her out of bed she demands assistance of two for safe transfers. The patient sits out usually only once a day over lunchtime.
She reports pain in right hip 5/10 and 2/10 in left knee from arthritis.
Assessment Tasks
1 What stage is her pressure area - _________ (1 mark)
2 Identify nursing actions to prevent further deterioration of the pressure area (3 marks)
INTERVENTION RATIONALE
1

2

3

3 What specific documents should be completed in relation to her pressure area? (3 mark)
1----------------------- 2 --------------------------------- 3------------------------
4 What nursing interventions should be carried out in view of her recent incontinence episodes?
INTERVENTION RATIONALE
1
2

3

(3 marks)
5 Access a BMI calculator and score her BMI - _________ (1 mark)
6 Identify 3 interventions that should be carried out to monitor and improve her nutritional status. (3 marks)
INTERVENTION RATIONALE
1

2

3

7 Complete the Barthel chart including the total (10 marks) BARTHEL INDEX OF ADL
Patient Name: Mrs West
Grade can be between 0 and the higher score ie requires some assistance
FEEDING
0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent
BATHING
0 = dependent
5 = independent (or in shower)
GROOMING
0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided)
DRESSING
0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.)
BOWELS
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent
BLADDER
0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent
TOILET USE
0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping)
TRANSFERS (BED TO CHAIR AND BACK)
0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent
MOBILITY (ON LEVEL SURFACES)
0 = immobile or 50 yards
5 = wheelchair independent, including corners, 50 yards
10 = walks with help of one person (verbal or physical) 50 yards
15 = independent (but may use any aid; for example, stick) 50 yards
STAIRS
0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent
TOTAL (0–100): ______
8 Based on the assessment, list 3 ways in which you can best help Mrs West get home quickly; and give explanations for each (3 marks)
1__________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2__________________________________________________________________________________________________________________________________________________________________________________________________________________________3_________________________________________________________________________________________________________________________________________________
SCENARIO 2 Jim has Alzheimer’s and is able to feed himself; but needs constant prompting otherwise he wanders or mixes his food.
He has had a fractured hip and has since been unstable on his feet. He insists he can walk but staff use the ceiling hoist to transfer him and staff transport him in a wheelchair around the building.
1 Complete the rating score based on the ACFI guidelines below by circling the correct answer
Readiness to Eat 0 – Independent Eating 0 - Independent
1 – Supervision 1 - Supervision
2 - Physical Assistance 2 - Physical Assistance
Rating A = 0 in both readiness to eat and eating
Rating B = 0 in Readiness to eat and 1 in eating
Rating B = 1 in Readiness to eat and 0 in eating
Rating B = 1 in Readiness to eat and 1 in eating
Rating B = 2 in Readiness to eat and 0 in eating
Rating C = 2 in Readiness to eat and 1 in eating
Rating C = 0 in Readiness to eat and 2 in eating
Rating C = 1 in Readiness to eat and 2 in eating
Rating D = 2 in Readiness to eat and 2 in eating RATING = ------ (1marks)
Transfer 0 – Independent Locomotion 0 - Independent
1 – Supervision 1 - Supervision
2 - Physical Assistance 2 - Physical Assistance
Rating A = 0 in both transfers and locomotion
Rating B = 0 in transfer and 1 in locomotion
Rating B = 1 in transfer and 0 in locomotion
Rating B = 1 in transfer and 1 in locomotion
Rating B = 2 in transfer and 0 in locomotion
Rating C = 2 in transfer and 1 in locomotion
Rating C = 0 in transfer and 2 in locomotion
Rating C = 1 in transfer and 2 in locomotion Rating D = 2 in transfer and 2 in locomotion RATING= ------ (1 marks)
2 What is the name for the commonly occurring behaviour of increased restlessness by clients with Dementia during the evening (1 mark)
--------------------------------------------------
3 What is the name of the therapy that is used by staff in dementia care to redirect behaviour; especially repetitive eg ‘I want to go home’, that is causing anger or frustration (1 mark)
--------------------------------------------------
SCENARIO 3
Mrs. Ruth Simmons is a right-handed, 70 year-old widow who lives alone in her own home, a two-storey single-family home. The kitchen and living room are on the main floor, along with the laundry, and the bedroom and bathroom are on the second floor.
Mrs. Simmons drives her own car. She is a member of a local handicraft club and enjoys needlework. Mrs. Simmons has two adult children who live in another suburb. Her daughter, phones weekly to talk to her mother. She hears from her son once or twice per month.
Medical Information
Mrs. Simmons called an ambulance after discovering that she was having difficulty walking and speaking. She was admitted to hospital, diagnosed with a left cerebral vascular accident (CVA).Mrs. Simmons suffers from hypertension and is taking prescribed diuretics. She takes Paracetamol 2 tabs 3 times daily for Osteo arthritis and hormone replacement medication .
Four days after admission, a Stroke-Rehabilitation Team Case meeting is due to take place. You are assigned as the case manager. You have already identified goals as follows:-
Client Goals
1. Mrs. Simmons wants to return to living alone
2. She wants to continue driving.
3. She wishes to continue leisure interest in needlework.
4. Mrs. Simmons wants to be able to speak more clearly;
5. Use of affected limbs, as much as future muscle tone allows
6. Reduce shoulder discomfort
7. Regain standing balance, and walking ability
Assessment Tasks
1. Identify members of the multidisciplinary team required to meet the client goals and what specific contributions will they manage (3 marks)
HEALTH PROFESSIONAL ROLE

2 What specific education should be given to a family if they wish to help with dressing their relative after a stroke; to prevent injury and make the task easier?
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------(3 mark)
SCENARIO 4
Mary has terminal cancer and no longer is able to eat adequate amounts of food. The Dr has recommended a naso-gastric tube be inserted but Mary is resistant to this suggestion,
What are the patient’s rights in this situation? (2marks)
What is our responsibility as Mary’s nurse in this situation? (1mark)
HLTEN51612 DIPLOMA OF NURSING
HLTEN515B Implement and monitor nursing care for older clients
Marking Guide
Assessment B Scenarios (40%)
Scenario Question Scenario’s Mark Mark Given
1 1
What stage is pressure area 1
2

Interventions 3
3
Specific documentation 3
4

Nursing Interventions 3
5

BMI calculation 1
6

Interventions 3
7
Barthel Index 10
8
3 ways to best help 3
Scenario
2 1
ACFI scores 1 mark for each section 2
2

Behaviour name 1
3
Therapy name 1
Scenario 3 1
Team members 3
2
Education 3
Scenario 4 1
Rights 2
2
Responsibilities 1
Total marks
40

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