Purpose of Assessment Task 2

The purpose of this assessment task is to provide you with the opportunity to engage with key knowledge and skills drawn from each of the five Unit Learning Outcomes (ULOs) and to demonstrate your ability to use this knowledge to organise and explain assessment findings, using principles of anatomy, physiology and pathophysiology and health assessment frameworks. Completing this task will assist you to engage with, and to demonstrate attainment of, key knowledge and skills drawn from each of the five ULOs.

Assignment question:
You are required to watch a specific video of a brief patient interaction whilst on a clinical placement. See the link below. You have also been provided with a written version of the ISBAR handover (see on the Cloud site).

Once you have watched the video, and read the ISBAR handover information, please
answer the following questions:

Part A

Using the information given to you in the handover of Mr Williams (ISBAR and video), as well as your own observations, measurements and assessments of the patient in the video, collect and describe as many assessment data/cues as you can.

Using a systems approach (outlined on pp 821-823 of the prescribed textbook by Jarvis (2016)), arrange this assessment data into meaningful clusters of health assessment data. Identify each piece of information as normal or abnormal.

These assessment findings should be documented using appropriate professional terminology. You can present this information in dot points or within a table (example table provided). No references are required.

DATA/ CUES / Signs and Symptoms. Indicate Normal (N) or Abnormal (A)
Neurological CNS
Subjective:
Objective:
Cardiovascular
CVS
Subjective:
Objective:
Respiratory Subjective:
Objective:
Genitourinary
Renal
Subjective:
Objective:
Musculoskeletal Subjective:
Objective:
Gastrointestinal
GIT
Subjective:
Objective:
Integument Subjective:
Objective:
Endocrine/
Metabolic
Subjective:
Objective:
Psychosocial/other Subjective:
Objective:

Part B

You have been asked by the Registered Nurse to conduct a focused assessment on Mr Williams. Nurses use the clustered cues to identify possible nursing problems, and focus their assessment on the identified problems. Often, this means undertaking further assessments on the patient to differentiate problems, monitor the progress of existing problems or potential problems. Three possible patient problems have already been identified for you.

(i) Identify two (2) additional relevant nursing problems (actual or potential) that may be present. For each problem (three provided and two of your own), provide a rationale using the clustered cues from Part A.

PROBLEM Supporting data (cues)
1. Pain
2. Fluid and electrolyte imbalance
3. Stress and anxiety

For each of the five (5) nursing problems,
(ii) Provide three (3) open ended questions for each nursing problem that you would ask Mr Williams and state your rationale for asking these questions.
(iii) Identify any additional physical assessments you would undertake to collect further data in relation to each nursing problem and explain why these assessments are necessary.
(iv) Describe the assessment findings/evaluation criteria you will use to identify improvement or deterioration of an existing problem; or the presence or absence of a potential problem.

No references required for this question.
We have provided an example (unrelated to Mr Williams) for you.

PROBLEM Assessment plan Rationale for assessment(s) Assessment findings or evaluation criteria
Eg: Nausea and vomiting related to medical therapy

Open ended questions: 1. Can you describe anything that brings the nausea on or makes it worse?

Further objective assessments:
1. Palpation of the abdomen Eg.. Establishes the predicating and exacerbating factors for the nausea
2. Nausea and vomiting can also be the result of other problems. Assessing the abdomen will help to identify/rule out other causes.
No further vomiting
Patient reported nausea well controlled with medications
Some tenderness secondary to vomiting, but no pain or guarding which may indicate more sinister problem

(v)  The nurse handed over that at the time Mr Williams’ pain score was 4/10 earlier, he was also tachycardic and tachypnoeic. Tachycardia and tachypnoea are common assessment findings for many nursing and medical problems, of which pain is just one. With reference to anatomy, hysiology and pathophysiology;
a. Explain the connection between tachypnoea, tachycardia and pain
b. Identify another nursing problem that may present with tachycardia and tachypnoea
c. Describe the assessments you would use to differentiate the two problems.

You may refer to an anatomy and physiology, pathophysiology, nursing or assessment text in this section.

Part C
Extended response question (500 words)
This question is about your ability to apply different assessment frameworks to the systematic collection of data for health assessments, and why developing the skills and knowledge to undertake comprehensive and systematic assessment is important for your future practice as a registered nurse.

You have already learned about several different assessment frameworks in this unit and others in the Bachelor of Nursing. Three common assessment frameworks are the biomedical approach (head-to-toe; body systems), functional approach (Jarvis, Forbes, Watt pp82-83; Berman et al. 2018, pp193-218), and the primary/secondary survey approach (Considine and Currey, 2015). Each approach has advantages and disadvantages in relation to the type of data collected, type of problems identified, and the context of the assessment. However, evidence suggests that nurses in acute care actually undertake little assessment outside of the collection of vital signs (Osborne, Douglas, Reid, Jones, & Gardner, 2015).

(i) Select at least two distinct assessment frameworks
(ii) With reference to the case study, Standard 4 of the NMBA Standards for Practice (Nursing and Midwifery Board of Australia, 2016), and relevant literature, discuss the strengths and weaknesses of your selected frameworks for guiding the collection of assessment data, and why comprehensive and systematic assessment will be important for your future practice as a registered nurse.

Your response should be in the form of a short essay. Your essay structure should be a short introduction (2-3 sentences), followed by 2-3 paragraphs, and a short conclusion (2-3 sentences).
References are required for Part C.

References
Berman, A., Kozier, B., Erb, G. L., Snyder, S., Levett-Jones, T., Dwyer, T., … Stanley, D.
(2018). Kozier and Erb’s fundamentals of nursing: concepts, process and practice (4th
ed.). Pearson Australia

Considine J, Currey J. (2015) Ensuring a proactive, evidence-based, patient safety
approach to patient assessment. Journal of Clinical Nursing, 24(1-2), 300-7.
doi:10.1111/jocn.12641

Jarvis, C., Forbes, H., & Watt, E. (2011). Jarvis’s physical examination and health
assessment (2nd Aust and NZ Edition). Elsevier Australia.

Nursing and Midwifery Board of Australia. (2016) Registered Nurses Standards For
Practice: Standard 4. Comprehensively conducts assessments. Retrieved from
http://www.nursingmidwiferyboard.gov.au/Codes-GuidelinesStatements/Professional-standards/registered-nurse-standards-for-practice.aspx

Osborne, S., Douglas, C., Reid, C., Jones, L., & Gardner, G. (2015). The primacy of vital
signs – Acute care nurses’ and midwives’ use of physical assessment skills: A cross
sectional study. International Journal of Nursing Studies, 52(5), 951-962.
doi:10.1016/j.ijnurstu.2015.01.014