Assessment Workbook

HLT51607 Diploma of Nursing (Enrolled/ Division 2 Nursing)
HLTEN504B Implement and evaluate a plan of nursing care
Assessment Workbook
Bhupinder Singh
Name ____________________________________________________
/conversion/tmp/activity_task_scratch/527860874.doc
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Element One
Establish and maintain therapeutic relationships with clients
It is very important as a nurse to promote therapeutic relationships between nurse and

client/ nurse and significant other / client and client / nurse and nurse / nurse and
multidisciplinary health team.
Please read this scenario and answer the following questions:
You are working an early shift at a hospital and you have been allocated your
patients for the day. One of your patients is a 68 year old man.
Your patient has a diagnosis of the following:
Cerebrovascular accident (stroke) 2 weeks ago with right sided weakness.
His past medical history includes hypertension for which he has recently been
prescribed medication and his past surgical history includes an
appendicectomy more than 30years ago.
Your patient’s CVA has not affected his speech but he speaks limited English
having migrated from overseas recently. He is married and his wife translates
for him when she visits each day.
Explain how you would determine the nursing care needs for this client
during your shift?
1. It’s very important to determine client’s nursing needs and do a required

assessment on them. This right handed weakness is called hemiparesis
and can cause loss of balance, difficulty in walking and right side
weakness.
Furthermore, I can use care plan to find out client’s medical history and based
an assessment on that. As here in this scenario, Client’s history has been
mentioned. Client has hypertension and first thing as a nurse, I will be doing is
checking his blood pressure using the sphygmomanometer to know if the
reading is similar to his regular blood pressure. Other than that, I will be doing
pain assessment as the client has an appendicectomy.
Appendectomy (appendicectomy) is surgery to remove the appendix. The

operation is usually carried out on an emergency basis to treat appendicitis
(inflamed appendix). Symptoms of appendicitis may include pain, nausea,
vomiting and constipation.
2
(http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Appendicecto
my)
How would you collaborate/ consult with your patient about his care
needs?
It’s very important to consult clients about their needs because the best person
can tell you about their needs are client. In this case, I will ask him if he felt
anything not normal in last 24 hours and if something? What was that?
Moreover, confirming if he is happy with all the service he is getting and any
change can make it better. I will be using therapeutic language and try to speak
slow and clear. As the client is 65 years old, he may find hard to understand
normal conversation speed and tune. Also, Using Interpreter services would be
a good idea if required.
Before implementing nursing interventions what are you going to explain

to the patient? Why would you do this?
Before implementing nursing interventions, I will explain to patient that what are
the interventions and about the procedure we are following. Before taking on
the procedure, it’s important to take patient’s consent. This will respect the legal
requirement of “client’s rights” also. If consent hasn’t been taken, I can be in
trouble legally. Moreover, Documentation of client’s consent needs to be done.
(http://www0.healthnsw.gov.au/policies/PD/2005_406.pdf
How could you establish and maintain a safe environment using

communication and interpersonal skills with the patient, family and other
health professionals?
It’s important to maintain a safe environment. It can be done by using

communication and interpersonal skills with patient, family and other health
professionals. I will explain all my actions or procedures to the patient and
family. I will also make sure to document actions taken. To communicate with
other health professionals, I will write “after shift notes” so that they could be
aware of current situation.
Your patient’s wife indicates to you that they don’t understand why he
has to take the recently prescribed medication. They do not understand
what the medication is or what it is for.
Explain what you are going to do in this situation.
I will explain the family about current medical condition and provide them
information about the drugs. I will suggest them to contact the doctor (who
prescribed the medicine) for more information. Doctor would be the best person
to explain the things to family and clear their doubts.
What are your responsibilities and what are you accountable for when
implementing care for this patient
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Quality has become a major focus within health care, especially in the areas of
regulatory quality, quality assurance, quality improvement and patient’s safety.
As a nurse, you are responsible and accountable for your actions. It is
important to take patients consent before going through any procedure. Also,
you are responsible for patient’s safety under the occupational health and
safety act. I am accountable for completing all the legal documents and respect
patient’s privacy and dignity.
Element 2
Assist clients in activities of daily living
Before you proceed you may need to revise the anatomy and physiology of
the integumentary system. You will need to know:
 the anatomy of the skin
 the major functions of the skin.
Once you have revised this you are ready to continue with the following
questions.
Chapter 37 of Tabnner’s Nursing Care (pp. 606 – 631)
SKIN CARE
Our actions in caring for the skin and mucous membranes of our clients are
based upon certain principles. These include:
(i) Unbroken skin and mucous membrane form part of the first line of defence
against infection
(ii) Skin and mucous membranes which are adequately nourished and
hydrated are more resistant to injury and infection
(iii) Adequate circulation of blood is necessary to maintain the vitality of all
living tissues
(iv) Body cleanliness improves self- esteem and resists infection
(v) Skin which is constantly wet may macerate and break down.
Remember, resistance to injury of the skin and mucous membranes

varies among people.
Which group/s do you think are most at risk of skin breakdown?
 People with Poor nutrition

 People who are Overweight and Underweight
 People who have impaired mobility and are bed bound
 People over 60 years old have high risk of skin breakdown
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 People who are incontinent of Urine or faeces
Showering or bathing are the most important part of promoting clean and healthy
skin. It is a nurse’s role to assist a client to wash if they are unable to complete the
task themselves. You will get a chance to shower someone at college, and will also
get to practice doing a bed bath. However, before you do, there are some important
points to remember:
 always preserve the dignity of a client – keep them covered when possible
 maintain privacy by closing the bathroom door fully
 maintain infection control principles by washing from the cleanest area (the
face) to the dirtiest (the groin/anal area)
 keep clients warm while showering/bathing
 be organised before you commence the task – organise towels, face washers
and clean clothes before you start
Showering or bathing is a good opportunity for a nurse to conduct a thorough

assessment of a client’s skin. Name five (5) things that you could observe
when showering someone:
 Tissue perfusion
 Skin dryness
 Wounds
 Any internal injury
 Pressure areas
 An infection that may not been seen when client is fully covered
 Pain
SHAVING
Shaving is often part of a male's usual daily hygiene practices. It promotes
comfort by removing whiskers that may itch and cause skin irritation. If a client
is unable to shave himself, you may be required to assist.
There are two types of razor, blade and electric. This is generally a personal
preference so be sure to ask before you begin.
Principles involved in shaving a client:

(i) shave in the direction of hair growth and keep the skin taut to prevent
cutting the client
(ii) use warm water and shaving cream or soap to soften the hair and prevent
pulling
(iii) Soap left on the skin causes irritation; therefore rinse the residual lather
from the skin after shaving. Many clients benefit from use of an emollient
cream.
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Before you proceed, you may need to revise the anatomy and physiology of
the oral cavity. You should know:
 The Anatomy of the oral cavity, including the lips, teeth and
tongue
 The functions of various structures in the mouth, including the
tongue, teeth and taste buds
 The role of saliva in maintaining a healthy oral cavity.
Once you have revised this area you are ready to begin the questions.
Oral hygiene is important to maintain the integrity of the oral mucous membranes, as
well as helping people to feel fresh, clean and comfortable. There are several ways
of cleaning someone’s teeth and mouth. Your choice of technique for providing oral
hygiene will depend on what is most comfortable and safe for your client. People
who are unable to swallow will need very different care than people who are simply
unable to walk to the bathroom to clean their teeth.
How would you provide oral hygiene care for a client who is unconscious?
 Pre-plan and place the equipment on the best location available

 Ensure that there is an adequate lighting
 Ensure privacy
 Position the client
 Ensure that suction equipment is available and working
 Get an assistant if needed
 Place towel under client’s cheek
 Place a towel under client’s neck
 Wash hands and wear gloves
 Use tongue depressor to help keep the client’s mouth open
 Inspect the mouth
 Gently and thoroughly swab all surfaces of the teeth, tongue and
mouth with appropriate mouth cleanser
 Clean teeth and oral cavity
 Report and document the procedure
(Tabbners Page 409)
Describe 2 conditions that affect the oral cavity
ORAL CANDIDIASIS
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Is candidiasis that occurs in the mouth. That is, oral candidiasis is a
mycosis (yeast/fungal infection) of Candida species on the mucous
membranes of the mouth.
(http://en.wikipedia.org/wiki/Oral_candidiasis)
PERIODONTAL DISEASE:
Periodontal disease is a type of disease that affects one or more of the periodontal
tissues:
 alveolar bone
 periodontal ligament
 cementum
 gingival
(http://en.wikipedia.org/wiki/Periodontal_disease)
Before you proceed, you may need to revise the anatomy of the gastro-
intestinal tract. You should know:
 the basic anatomy of the GIT
Once you have revised this area you are ready to begin the questions
Can you think of any factors that might affect a person’s ability to, or
interest in, eating and drinking:
There are many factors that can directly affect person’s ability to or interest in
eating or drinking. It could be physical state where someone is not able to eat
or drink because of pain or may be unable to swallow. Other factors could
relate to mental state of mind such as depression or mental trauma.
Before you commence feeding someone there are a number of points to

consider:
 Prepare the environment by:
removing unpleasant odours
clearing the over bed table
 Preparing the client by:

reduce anxiety/stress
sit upright
offer the chance to use the toilet
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 Prepare yourself by:
wash hands
position yourself at eye level.
Other points to remember:

 Make sure the food served is appropriate
 Offer small meal that are attractively served
 Ask the client how they wish to eat their meal
 Never force someone to eat
 Don’t rush the feeding
 Encourage independence by using special eating utensils
 Remove lids, open packages if needed
 Butter toast and cut up meal if required
 Place a serviette under chin if desired.
 Talk to client while feeding them.
 Offer mouth care after eating
 Record/note amount eaten.
Who would you consult with to make sure your patient’s nutritional
requirements are being met?
In this situation, I would consult with Dietitian who is experts in food/Nutrition

settings and habits. According to me, they are best person available to consult
about nutrition requirements.
What is dysphasia?
DYSPHASIA refer to difficulty in communicating
(Tabbner Page - 787)
What can you do to assist someone who has swallowing problems?
- Providing meals comprised of thickened fluids

- Refer the case to speech pathologist to find out the reason of the
cause
- Supervise them and feed them if required
- Monitor the oral area and while feeding, putting the food in an
unaffected area to prevent any further damage
(Tabbner Page – 658)
What would you do to assist someone who was choking on their meal?
It could be tricky to assist someone with meal if they start choking. In this
scenario, you have to follow procedure: Bend the person forward and give 5
blows at their back and if they still continue to choke, give them 5 chest blows
keeping the other hand on their back to support (Also check after each blow if
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blockage has been removed) and in case they still continue to choke, contact
the medical emergency as soon as possible. (www.wikipedia.com/choking)
Give definitions for the following words that relate to elimination:
SUPPOSITORY: A drug delivery system that is inserted into the rectum,

Vagina or Urethera where it dissolves and melts.
(http://en.wikipedia.org/wiki/Suppository)
ENEMA: is the procedure of introducing liquids into the rectum and colon via
the anus. The increasing volume of the liquid causes rapid expansion of the
lower intestinal tract, often resulting in very uncomfortable bloating, cramping,
and powerful peristalsis, a feeling of extreme urgency and complete evacuation
of the lower intestinal tract. An enema has the advantage over any laxative in
its speed and certainty of action, and some people prefer it for this reason.
(http://en.wikipedia.org/wiki/Enema)
CATHETER: is a thin tube extruded from medical grade materials serving a

broad range of functions. Catheters are medical devices that can be inserted in
the body to treat diseases or perform a surgical procedure. By modifying the
material or adjusting the way catheters are manufactured, it is possible to tailor
catheters for cardiovascular, urological, gastrointestinal, neurovascular, and
ophthalmic applications.
(http://en.wikipedia.org/wiki/Catheter)
APERIENT: A drug used to relieve constipation.
DIURETIC: is any substance that promotes the production of urine.

(http://en.wikipedia.org/wiki/Diuretic)
What is a stoma?
A stoma (or ostomy, these 2 words mean the same thing) is a surgically created
opening on the abdomen which allows stool or urine to exit the body. There are 3
main types of stoma – colostomy, ileostomy and urostomy. You should ask your
medical team which type of stoma you have/are going to have as there are some
differences between them.
Generally, your stoma will be pink and moist (like the inside of your mouth) and a little
swollen after your operation. This will reduce over a period of between six to eight
weeks. There are no nerves in your stoma so there will not be any sensation when you
touch it. Everyone’s stoma is different in shape and size, so don’t worry if yours
doesn’t look like the ones in this leaflet.
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(http://www.ostomylifestyle.org/content/what-stoma)
Who are 2 members of the multidisciplinary health team who could assist
the client with education and support if they require a stoma and what are
their roles?
Stoma Therapist and Dieticians are the team of two multidisciplinary health
professionals who can assist the client with education and support if they
require stoma. Role of dieticians is to provide diet chart for the patient after
operation and stoma therapist to provide support post operation.
Name the two reasons why a person may have an indwelling catheter:
Urinary catheters are used to drain the bladder. Your health care provider may
recommend that you use a catheter if you have:
 Urinary incontinence (leaking urine or being unable to control when you

urinate)
 Urinary retention (being unable to empty your bladder when you need to)
 Surgery on the prostate or genital
(http://www.nlm.nih.gov/medlineplus/ency/article/003981.htm)
What is a suprapubic catheter?
A suprapubic catheter (tube) drains urine from your bladder. It is inserted into
your bladder through a small hole in your belly. You may need a catheter
because you have urinary incontinence (leakage), urinary retention (not being
able to urinate), surgery that made a catheter necessary, or another health
problem.
(http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000145.htm)
List five nursing actions that could be implemented to prevent a client

with an indwelling catheter developing a urinary tract infection.
Following are the Nursing actions could be implemented to prevent a client with
an indwelling catheter developing a urinary tract infection: -
 Hand Hygiene
 Use of gloves
 Swab outlet valve with alcohol swab when emptying the bag
 Client should be hydrated
 Keep IDC in the correct position
(Tabbners Page 687-689)
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Give 2 reasons why would you complete a fluid balance chart for a patient
It’s important to complete a fluid balance chart for a patient to access hydration
status and monitor urinary output. Also, it’s useful to keep track of the record to
avoid any further complication.
(Tabbner Page: 546)
Why would you complete a bowel chart for a patient?Explain 2 reasons
why you need to be accurate in your documentation
It is a legal requirement. Also, it is a way of communication between medical

staff so accuracy is must. Any wrong information could result in harm to patient.
While completing your documentation you notice your patient’s input has
altered significantly from the day before. What will you do with this
information?
In this case, I would let Registered Nurse know as soon as possible and also,
document the changes.
Please review pages 510 – 516 in your Tabbners “Alternative methods to

meet nutritional needs’ and then complete the following
Give 2 examples when enteral feeding may be required
 Malabsorptioneg
 Dysphagia.
(Tabbners Page - 661)
How do you check the tube position?
Tube position can be checked by these 3 methods:
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Auscultation: It involves installing air into the feeding tube with a syringe while
using stethoscope placed over the stomach to listen for rushing air.
Bubbling: This method involves observing bubbles when the end of the feeding
tube is placed under water; the appearance of bubbles is thought to indicate
that the feeding tube is misplaced in the respiratory tract.
Aspirate Appearance: This method involves assessing the appearance of

aspirate from the tube. Ordinarily, small bowel aspirates are golden yellow or
greenish brown.
(Patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2006/Dec3(4)/Pages/
23.aspx)
Before commencing the next questions you will need to revise the anatomy
and physiology related to the respiratory system. You should be able to:
 describe the anatomy of the respiratory system
 describe the major functions of the respiratory system
 describe the process of respiration
Once you are able to do this you are ready to continue with the following
questions.
Chapter 40 in Tabbner’s Nursing Care, the section Factors affecting

respiratory function (pp. 662 – 664). This chapter begins with a good overview
of the process of respiration that may be helpful to read before you continue.
A cough can be described as productive or non-productive. Explain the

difference between each. Why do you think it is important for a nurse to know
what sort of cough a client has?
Productive Cough is when sputum is swallowed and cough sounds moist whereas
non-productive cough is when sputum is not swallowed and cough sounds dry. It is
important to know type of cough for a nurse to treat the client accordingly. Being
aware of sputum production will also draw our attention to whether there is a presence
of blood in the sputum.
(Tabbners Page: 494)
Infective respiratory disorders are very common – everyone has experienced

an upper respiratory tract infection (URTI), otherwise known as a cold, at one
time or another. Respiratory infections are caused by a pathogen, such as
bacteria, viruses or fungi, infecting a part of the respiratory system. Some
respiratory conditions like a cold are merely unpleasant; others like whooping
cough, pneumonia and tuberculosis can be far more serious and can even be
life-threatening.
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There are many ways that nurses can assist a client with a respiratory disorder.
These will of course depend on the condition that the client is diagnosed with,
and what treatments have been ordered for the client. We will only focus on a
few of the most common nursing interventions, including oxygen administration
and oximetry, nebulisers, puffers and peak flow assessment. We will look at
some of the activities performed by physiotherapists or nurses that can assist
these clients.
Encouraging clients to practice deep breathing and coughing facilitates lung

expansion, thereby assisting with oxygen and carbon dioxide exchange and the
removal of secretions. Prior to encouraging a person to cough, check to
ensure this action is not contraindicated. What instructions would you give
to someone when asking them to perform deep breathing and coughing
exercises?
DEEP BREATHING:
First thing you will do as a nurse is to place client in a sitting position to

promote optimal alveolar expansion. Then put one hand on the chest
and the other hand on the abdomen and tell client to inhale deeply and
slowly, pushing the abdomen out.
COUGHING EXERCISES:
Coughing exercise is done by placing client in a sitting position and

instructs them to cough and to expectorate any sputum production
(Tabbners Page: 514-516)
Postural drainage
Postural drainage helps drain secretion collected in the respiratory tract by
using gravity to assist the movement of the fluid from various lung segments.
Clients are asked to lie in different positions to move secretions from different
sections of the lungs. Postural drainage will be ordered by a physiotherapist
and should be performed with their guidance.
On page 682 of your textbook there is a diagram of different positions used for
postural drainage. Try putting yourself into these positions. Are they
comfortable?
Suctioning
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Suctioning is performed to remove secretions from a client’s airway, and
therefore helps to maintain a client’s airway if they are unable to do so
themselves. The oral cavity can be suctioned using a Yankauer sucker (see
the picture below. The nasopharynx and oropharynx may also be suctioned
using a suction catheter.
Yankauer sucker
When suctioning a client you need to remember that the respiratory tract below
the oral cavity is sterile, and therefore you must take specific precautions so
that you do not introduce pathogens. Describe how you will retain sterility
of the respiratory tract while you are performing suctioning for a client:
 Make sure that suction catheters remain sterile.

 Use water suitable for flushing the catheter.
 Use tongue depressor to hold down tongue when introducing
catheter into the mouth or nose.
(Tabbners Page 511)
Assisted ventilation
When someone is having difficulty breathing by themselves, there are a
number of different sorts of machines that can assist them. Some machines
take over the role of breathing altogether – these are called ventilators, and are
most commonly seen in the operating theatre or in the intensive care unit. A
person requiring mechanical ventilation needs specialised care that only
experienced and trained nurses provide. Clients requiring ventilation will need
to have an artificial airway inserted.
Name 2 different sorts of artificial airways.
 Orpharyngeal Airways
 Nasopharyngeal Tube
 Endotracheal Tube
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What is a tracheostomy? When would a client have one created?
Tracheotomy is a surgical creation of an external opening into the trachea and may be
performed as an emergency temporary measure or as a permanent measure. A client
would have one created to
- prevent aspiration of secretions
- allow removal of tracheobronchial secretions by suction
- Permit the use of a mechanical ventilation device.
Pulse oximetry
Pulse oximetry is widely used in clinical nursing as away of monitoring how
effective a client’s breathing pattern is at supplying the body with oxygen.
Pulse oximetry measures oxygen saturation in the blood (sometimes written as
SpO2). Pulse oximetry measures the amount of light passing through an area
(generally a finger or toe) and measures how much haemoglobin is in the area
by determining the difference in the amount of light that can travel through
oxygenated and deoxygenated haemoglobin. What is the normal range for a
pulse oximetry reading?
95% and more
Name three things that could affect the reading you receive from a
pulse oximeter:
 Client motion
 Anaemia
 Conditions that decrease arterial blood flow
(Tabbners Page: 319-320)
Oxygen therapy
It is important that you realise oxygen is a therapeutic substance and that there
are dangers associated with its use. You must administer oxygen only
according to legal instructions and with due care for the client and the
equipment. Oxygen may be potentially hazardous to the person to whom it is
being administered. It may also cause discomfort in its administration.
Why is oxygen therapy prescribed?
To decrease the workload of the cardio pulmonary system and to protect the
Patient from tissue hypoxia.
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Oxygen can be administered via:

 nasal prongs
 intra nasal catheter
 mask
Each method of administration has different indications and a different

maximum flow rate. For each method describe why you would use it and what
flow rate you can use:
Nasal prongs Intra-nasal catheter Oxygen Mask
Used when low or medium Used when an oral route is Used when patient
concentration of oxygen is not available. Flow is as required higher
required. Minimum flow is prescribed by the doctor. concentration of oxygen.
0.25 L/Min to 3L/Min Flow rate is 5-10L/Min
(Tabbner Page: 526)
(http://www.health.wa.gov.au/CircularsNew/attachments/567.pdf)
Some points to consider:

 Oxygen may come from a wall outlet or a cylinder
 The oxygen and the flow rate should always be ordered by a doctor
 Oxygen should be treated as medication – therefore you need a valid order.
You should check the order as you would a medication and document
appropriately.
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 Oxygen is not humidified unless ordered. The water in a humidifier provides
a medium for the growth of micro-organisms and predisposes the client to a
chest infection. If there is excessive drying of the mucous membrane lining
of the respiratory tract then humidification may be ordered. If this occurs
then the humidifier must be sterilised, sterile water used and change
frequently e.g. once per shift.
Nebulisers
Nebulisers are an apparatus used for converting liquid to a fine spray.
Reasons for use: To deliver medications

To moisten secretions
To relieve bronchial spasms.
Nebulisers are no longer the administration method of choice for respiratory

drugs, although they are still used at times. Why are they no longer
favoured?
Nebulisers are no longer the administration method of choice for respiratory drugs
because they are more time consuming and it could be dangerous during sudden
asthma attack.
Points to remember about administering a nebuliser:

 check medication with RN
 do not use oxygen unless ordered
 instruct client to sit up
 once the mask is placed on their face ask then to inhale deeply and slowly
through their mouth and out through the nose.
Drugs may be inhaled so as to deposit them at the site at which they are to
work (target tissues), which is the lining of the bronchioles. This is a form of
topical application. This decreases possible side effects by only making the
drug available at the site where it is required.
Inhaled drugs may be in the form of a powder or, more usually, a liquid in a
very fine spray known as an aerosol. These are dispensed through a metered
dose inhaler (MDI), which is a metal canisters that contains the medication and
a gas under pressure. The gas is a propellant and drives the medication out
when the inhaler is pressed.
MDIs should always be used with a spacer. A spacer is a large plastic device
that is attached to the MDI.
Why is it important to use a spacer?

How do you clean a spacer?
- It ensures that more medication gets into the lungs than just using a
puffer
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- It reduces side effects of inhaled steroids found in preventer medication.
The spacer can be taken apart and washed in clean warm water with
dishwashing detergent and allowed to be dry.
(http://www.asthmaaustralia.org.au/spacers.aspx#Why_should_I_use_a_spacer)
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Collecting a sputum specimen
A sputum specimen is collected to enable any pathogenic organisms to be

identified and the appropriate treatment implemented. A specimen can be
obtained either by asking the client to expectorate into a sterile container, or by
using suction equipment to obtain the sample.
Sputum specimens are generally obtained first thing in the morning. Why is
this specimen the best?
Sputum specimens are collected first thing in the morning, before food and fluid is
consumed and this makes sure that there is an accumulation of secretions to be taken.
(Tabbner Page 515)
Before collecting the specimen ask the client to rinse their mouth out with
water. Why would you do this?
It is done in order to clear micro-organisms from client’s mouth and obtain

required oral hygiene level.
It is essential to collect sputum and not saliva. A sample of saliva will not be
able to be tested for pathogens in the respiratory tract. What does normal
sputum look like?
Normal sputum looks clear but may be white if the client
- smokes
- Or has a viral infection.
(Tabbners Page 515)
What does infected sputum look like?
Infected sputum may be yellow, rust-coloured or green to dark brown.
(Tabbners Page 515)
When a specimen has been obtained it will be sent to the laboratory for
culturing. This is often on the request form as M, C & S. What does this stand
for?
Microbial Culture and Sensitivity.
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Element Three
Assist with the movement of a client
Before you proceed, you may need to revise the anatomy of the
spine. You should know:
 the anatomy of the spine
 the function of “discs” in the spine
 the correct curvature of the spine.
Once you have revised this area you are ready to begin the next section
Body Mechanics involves three basic elements:
 Body Alignment
 Balance
 Co-ordinated Movement
Describe good Body Alignment
Proper body alignment can be described as the weight distribution on the whole skeletal
structure. It is very essential for the safety and efficient use of body mechanism. It is basically
aligns all the body segments in a proper and healthy order.
(www.ask.com/question/what-is-proper-body-alignment )
Balance involves centre of gravity, line of gravity, body alignment and support base.
Define:
Gravity: The force that attracts a body towards the centre of the earth, or towards any
other physical body having mass.
Centre of gravity : A point from which the weight of a body of system may be
considered to act.
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Support base: Area defined by the parts of the body and assistive devices that
are in contact with the supporting surface.
(http://medical-dictionary.thefreedictionary.com )
Co-ordinated Movement involves:

 Reducing friction
 Leverage
 Smooth fluid movements.
How do these concepts apply to nursing? Give examples.
Ways that you can minimise body strain during physical activities include:
 adjusting the working area to waist level

 increasing body stability by widening your base and lowering your
centre of gravity
 using major muscles, e.g. legs rather than back
 avoiding working against gravity
 holding objects close to the body when lifting
 when lifting or picking objects up squat rather than bending your back
 keeping your back in neutral.
What other ways can you think of?
Other ways to decrease strain during physical activities are it make sure knees are
bending and feets are in proper position. Also to weigh the weight before lifting is a
good idea to see if your body can handle it.
REMEMBER:
 a client should be encouraged to be independent
 never pull on a client's shoulder
 always stand on the client's weaker side
 transfer with client’s strong side leading
 safety aspects and how to minimise body strain
Manual handling is one of the highest risk activities in nursing. Lots of nurses
sustain a manual handling injury during their career. Most involve back pain
and are often related to assisting people to move.
21
We have looked at some of the basic safety principles associated with manual
handling. List 3 ways that you can make manual handling tasks safer:
- Lift heavy objects using correct body posture (Knee bending and feets are in
proper position)
- Face the direction of movement
- Stretch for 10 minutes a day to strengthen abdomen and lower back
(Tabbner Page 571)
Many health care agencies now have a “no lift” policy. This means that nurses
do not physically lift clients. Instead, a range of equipment is available to assist
with the movement of client’s who are not able to move independently.
What equipment do you know that can assist in moving a client?
Hoists, fabric sheets and Wheelchairs are most frequently used equipments for lifting
clients.
Sometimes, people who nurses care for will require assistance to moving. This
may mean that they require assistance moving around in bed or walking
around, or they may require assistance moving from one place to another, eg.
from their bed to a chair. Part of a nurse’s role is to assist clients to move when
they are unable to do so without assistance.
Identify a situation involving a patient of risk or potential risk. What

strategies can you think of to minimise harm to yourself and others?
Situations having potential risk to a client could be getting in and out of the bed.
Other difficulties could be sitting on toilet and self use of the shower. Strategies
to minimize the harm:
- Leave a patient bell on their pillow so that they could call you
whenever needed
- Use hoists and fabric sheets to transfer patients
Who do you report identified manual handling risks to?
In the case of manual handling risks, I would report to Nurse Manager or the
OH&S representive at my workplace.
Explain under what circumstances you may use a slide sheet to assist in
moving a client:
22
I may use slide sheet in the circumstances where patient is unable to move or
slide independently.
What other options do you have is you are not able to use a slide sheet?
In the absence of slide sheet, I can use rigid sliding device or linen. And
while Transferring Patient bed to bed or bed to wheelchair, I would use
Hoist.
Explain why a zimmer frame and a walking stick aid in balance.
Zimmer frame and walking stick are helpful in providing support and sense of
security to the patients. It maintains their independence and keeps up their
moral. They are not dependent on others to move and it could be major mental
strength booster for them. Moreover, they reduce fatigue.
In which circumstances would you use a hoist to transfer a client?
Hoists are mainly used if client is bed bound and not able to move
independently.
When is the use of a hoist contra-indicated?
.Use of a hoist in contraindicated

- if the patient’s spine is unstable
- Patient is not organised
If the patient is violent or scared on the hoist, it can cause injury.
List five safety factors to consider when using a hoist
 Get staff member to help you
 Pre Plan with your partner about your roles
 Ensure that client is in safe condition to be left on the hoist i.e. no back
injury or pain
 Some patients may have physical constraints such as size or rigidity
 Ensure use of correct size of sling prior to use of hoist
23
(http://www.youtube.com/watch?v=plKck-z2b00)
Describe the actions you would take to assist a client who had fallen?
 Assist them while they are on the floor

 Take vital signs and neurological observations
 Scan the body to investigate the areas client has a pain
 Call the ambulance in the case of spinal, head or any other severe injury
 If nothing serious, use hoist to pick the client up to the bed
 Complete all the paper work including incident Report chart and put an
incident in client’s progress note file
 Let supervisor know and follow the orders
(http://www.health.vic.gov.au/agedcare/maintaining/falls_dev/downloads/B
1BB3(b)Falls%20Risk%20Screening%20and%20Action%20Plan%20Tool
%20CC%20workers%20guidelines.pdf)
Range of motion exercises involves putting the joints through movements they
are capable of. They may be performed actively or passively.
 Passive exercises involve intervention and are the movement of part

of the individual’s body by another person.
 Passive exercises help to prevent contractual deformities of joints
and are performed when an individual cannot move or exercise
independently
 Activities are individually designed
List 5 benefits of Active Exercise
 Exercise controls weight

 It provides better blood circulation within the body
 Exercise combats health conditions and diseases
 Exercise boosts energy
 It provides strength to our immune system to fights the diseases
24
(http://www.mayoclinic.com/health/exercise/HQ01676)
Now review the section about Decubitus Ulcers (pp.626-631) in Tabbner’s Nursing
Care
Decubitus ulcers are caused by either intrinsic or extrinsic forces, or a

combination of both. Explain the terms intrinsic and extrinsic:
Intrinsic Forces: Forces that originates solely within the body i.e. Internal
Extrinsic Forces: Forces that originates from outside the body
(http://www.jappl.org/content/95/4/1361.full)
(http://www.thefreedictionary.com/intrinsic)
(http://www.thefreedictionary.com/extrinsic)
Identify common sites of decubitus ulcers
Common sites of decubitus ulcers (Pressure areas) are ankle, elbow, hip, heel,
shoulder, inner knees, back of the head, lower back and buttocks
(http://www.webmd.com/skin-problems-and-treatments/common-areas-
where-pressure-sores-develop)
Draw an arrow to the common sites on this diagram
25
Ankle, elbow, hip, heel, shoulder, inner knees, back of the head, lower back
and buttocks are the pressure areas in above given diagrams.
The primary causes of decubitus ulcers or pressure sores include the following.
Please explain them.
Compression: Pressure ulcers occur when soft tissues (most commonly

the skin) are distorted in a fixed manner over a long period. This distortion
occurs either because the soft tissues are compressed and/or sheared
between the skeleton and a support, such as a bed or chair when the
person is sitting or lying, or because something is pressing into the body,
such as a shoe, surgical appliance or clothing elastic.
26
Shearing: Shearing of soft tissue occurs when forces moving in different
directions are applied to the same tissue mass. For example, if a person is
sitting up in bed, the skeleton tends to move towards the feet as gravity
drags the upper part of the body downwards.
Friction: Friction, as well as pressure and shear, is also frequently cited as a

cause of pressure ulcers. This is, of course, true in the indirect sense that
friction is necessary to generate shearing forces.
(http://www.nursingtimes.net/part-1-causes-of-pressure-ulcers/206473.article)
What are the four stages of pressure ulcers?
Stage I: Intact skin with non-blanchable redness of a localized area usually

over a bony prominence. Darkly pigmented skin may not have visible
blanching; its colour may differ from the surrounding area. The area may be
painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I
may be difficult to detect in individuals with dark skin tones.
Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer
with a red pink wound bed, without slough. May also present as an intact or
open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer
without slough or bruising. This stage should not be used to describe skin tears,
tape burns, perineal dermatitis, maceration or excoriation.
Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone,
tendon or muscles are not exposed. Slough may be present but does not
obscure the depth of tissue loss. May include undermining and tunnelling. The
depth of a stage III pressure ulcer varies by anatomical location. The bridge of
the nose, ear, occiput and malleolus do not have (adipose) subcutaneous
tissue and stage III ulcers can be shallow. In contrast, areas of significant
adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is
not visible or directly palpable.
Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle.
Slough or eschar may be present on some parts of the wound bed. Often
include undermining and tunneling. The depth of a stage IV pressure ulcer
varies by anatomical location. The bridge of the nose, ear, occiput and
malleolus do not have (adipose) subcutaneous tissue and these ulcers can be
shallow. Stage IV ulcers can extend into muscle and/or supporting structures
(e.g., fascia, tendon or joint capsule) making osteomyelitis likely to occur.
Exposed bone/tendon is visible or directly palpable. In 2012, the NPUAP stated
that pressure ulcers with exposed cartilage are also classified as a stage IV.
(http://en.wikipedia.org/wiki/Pressure_ulcer)
Name three factors that will make a client more at risk of developing a
decubitus ulcer:
27
1. Inability to move
2. Poor health or weakness
3. Age
(http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=risk-
factors)
Older people are more often to get decubitus ulcer as with age, their ability
to move decrease. It results in not sufficient supply of blood in pressure
areas and sore start building.
It is important to identify those individuals at risk of developing pressure areas,

and many assessment systems have been designed to aid identification. Two
scales, the Norton Scale and the Braden Scale, are discussed in your textbook.
When you are on clinical practice familiarise yourself with the form used in the
health facility
Preventing pressure ulcers is a critical nursing role. The best possible way of
dealing with a pressure sore is to prevent it from ever occurring. Discuss each
of the nursing care strategies listed below and give examples of how they can
be achieved.
Skin Care:
 Avoid hot water

 Use mild cleansing agent that minimize irritation and dryness of the skin
Regular assessment:
 Fully assess the body while showering

 Make sure to do pain assessment on areas more often to get effected with
pressure sores
Regular positioning
 If client is bed bound, try to change their positions regularly as it will

provide full blood flow throughout the body
Preventing pressure
 Use pressure relieving devices

 Regular body assessment
(http://www0.health.nsw.gov.au/resources/quality/pdf/pressure_ulcers_commc
are.pdf)
Pressure Relieving Devices

There are a number of pressure relieving devices on the market that are
designed to reduce pressure, help maintain skin integrity or reduce friction
28
while transferring. Research each of the pressure relieving devices listed
below and discuss the effectiveness of each.
Sheepskins
They are fully feet covered linen which provide protection against external force
and internal such as pressure sores. It is soft and comfortable to wear. It is fully
protected device and can be on feets throughout the day even during daily life
activities.
Foam boots
 Comfortable foam material

 Suspends the heel to help reduce pressure
 Ventilation holes help prevent heat build up
 Constructed with hook-and-loop closure for easy adjustment
 Removable foam block included to increase heel suspension
Foam mattresses
Pressure points are significantly reduced, up to 80%, which only memory foam
can provide. Tossing and turning is the leading cause of a poor night's sleep
which is drastically reduced with a memory foam mattress.
(http://www.myessentia.com/research/foam-vs-spring)
Air mattresses
These alternating pressure mattresses are designed to prevent the occurrence

of back problems and reduce the risk of pressure sores, ulcers and other
pressure related medical conditions.
(http://www.invacare.com.au/index.cfm/1,90,0,40,html/Pressure-Care)
29
Element 4 Prepare clients for procedures
Patients may undertake many procedures while in hospital and the nurse must
prepare the client for them.
Why is it necessary to provide each client with a full explanation of the

procedure?
 It is a legal requirement and client’s right

 It will provide client’s with peace of mind
 They will be more calm and composed
 Clients can provide you with relevant information which could be helpful
in the procedure
 Clients will feel secure and it will build a rapport
What is valid consent?
It is to give approval, assent, or permission. A person must be of sufficient

mental capacity and of the age at which he or she is legally recognized as
competent to give consent. It is necessary to legally document the consent.
(Mosby's Medical Dictionary, 8th edition)
How could the nurse maintain dignity and privacy through out the
procedure?
Client’s dignity and privacy are very important and legally should happen every
time nurse interacts with client. It is must to remember that it is client’s right.
Proper and clear documentation of the client notes, treating them fairly,
respecting their decisions are examples of respecting client’s dignity and
privacy.
If the patient had concerns about the procedure who will you report this to?
30
Registered Nurse/Nurse Manager.
Element 5
Provide nursing care to meet identified needs
When caring for someone who is in pain or unable to sleep you may need to
position someone in such a way as to help them get more comfortable. You
know what it’s like when you can’t sleep – you toss and turn and just can’t get
comfortable. It’s the same for our patients, but sometimes they aren’t able to
change positions themselves and so we need to assist them.
At college, practice positioning your partner in the following ways:
 Supine
 Upright (sitting)
 Lateral
 Fowler’s
 Prone.
You may need to work out where best to use pillows to aid in positioning your
patient comfortably in each of these ways.
Which position do you think would be most comfortable for someone with a
respiratory illness? Why?
In the situation of respiratory illness, I would put patient in the upright position in order to
facilitate alveolar expansion.
When would you place someone in a lateral position?
31
 When someone is not conscious. It will open airway and prevent oral
secretion to the trachea
 In the situation of anaesthesia
(http://ceaccp.oxfordjournals.org/content/4/5/160.full)
 When treating rectum
Please now read Tabbner’s Nursing Care (pp. 575)
Why do you make a client’s bed?
It’s important to make client’s bed in order to give them feel of ease and
comfort. An untidy bed can make them uncomfortable and sense of calm can
turn into restlessness. Also, In order to prevent pressure sores, a tidy bed is a
vital asset with a proper position of pillows.
Sometimes you do not have a second person to assist you. How do you think
that you could save time and energy doing this procedure by yourself?
It is important to get someone to assist you while making a bed. In case it is not
possible, just to make sure that you bed your knees while getting down and
maintain proper position of the feets. A proper positioning will save you energy.
Moreover, in such situation you are the only one who makes decisions and it
will provide you with an opportunity to do it the way you expert or learnt. (As I
am on a practical hospital training, Sometimes the procedure they follow in the
hospital is different to what I have learnt in the class but being a student nurse,
I have to follow them but given an opportunity to do it the way I have been
taught in the class I think I would be quick),
Bed linen can be a source of bacteria and other pathogens, and must be handled
with care. You should never shake or flick bed linen because it can spread bacteria
over large area. Similarly, you should never hold linen against yourself, because it
can transfer pathogens onto your uniform.
Where do you place clean bed linen when making a bed?
I try to be organised and get ready with the equipments I am going to use. So I put
the bed linen on the trolley alongside all the clean sheets.
What do you do with soiled linen that you remove from the bed?
Soiled linens are placed in the foul bag. Foul bad contains all the soiled linen
and bed sheets.
32
When you are making a client’s bed, what would you do with :
 The client’s locker stays wherever it is. In the situation where you need
more space to move, you can push the locker on the side but
to make sure its on the original position after you finish making
bed.
 Chair beside the bed can be moved in order to get more area to work
around.
 Linen carrier need to be placed in the position you could easily access it.
 Client’s bell can be hanged up the wall behind the bed. It is must to ensure
that you provide client with a bell after making the bed.
Please now read the following scenario and answer the following questions.
33
You have an elderly patient amongst others to care for during your shift.
The nursing care plan states the patient has a daily shower and requires full assistance.
What OH & S factors would you need to consider before undertaking this procedure
to ensure a safe environment for your patient?
 Ensure that there is a clearway between room to the shower room

 Make sure floor is not slippery
 Shower room need to be tidy and clean
 Ask patient about their preference of hot or cold water. You can put some
drops on their hand to held it onto the desired temperature
 Ensure that they get dry up in the shower room to prevent any slip or fall
 Use non slippery mat under the client’s feet when standing them up in the
shower
How would you maintain the dignity, privacy and comfort of your patient?
 Ensure that you close the door before taking patient’s clothes off
 If patient is using a toilet and safe to do by themselves, it is a good idea to leave
and ask them to call you when they finish
 Encourage patients to do as much as they can themselves
When undertaking the procedure what infection control measures would you need
to consider?
It is important to be aware of client’s health and behaviour before you take them to the
shower. If someone seems unwell, it is always a good idea to check their temperature
(Full vital signs if possible). Moreover, If they have open wounds and cannot be
exposed to the water, ensure that they are fully covered.
You are ready to undertake the shower and you realise observations are due at
the same time, what task will you do first and why?
In this scenario, I will ensure that observations are taken before the shower. In the
situation, where client is unwell It could be risky to expose their body to the water.
.
The shower is completed; patient is back in bed and then asks for medication.
Considering your current level of training are you going to give this medication?
Give rationale for your answer.
Under the law, being a student Nurse I cannot assist clients with medication. It is not under
my roles and responsibilities and it is illegal for me to take any decision on client’s
medication. In the near future when I am an enrolled nurse, Medication is the area I am
looking forward to.
HLTEN504A Implement and evaluate a plan of nursing care Workbook V.1 2010
34
UNCONTROLLED IF PRINTED
Who will you report this request for medication to?
I will report it to Nurse Manager or the Register Nurse available on the shift.
You have identified your patient cannot reposition himself easily in bed.
What prevention strategies could you consider to prevent decubitus ulcers?
 People who spend most of their time in bed are advised to change position at least
once every two hours, even during the night, and to avoid lying directly on their
hipbones.
 Pillows may be used as soft buffers between the skin and the bed or chair.
 Use air mattress or other pressure relieving devices
 Bed sheet needs to be clean all the time
 Use moisturizers. Ensure that skin is not dry
 Assess skin in the shower or whenever possible to.
(http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pressure_sores)
Element 6
Monitor and evaluate clients during care

Before you proceed read Chapter 21of Tabbner’s Nursing Care
(pp. 251 – 274) to revise vital signs then answer the following.
Temperature
Body temperature is maintained within a fairly constant level by the hypothalamus.
There is a balance between the heat lost and the heat gained. Revise how heat is
lost and gained by the body.
What are the normal ranges of temperatures taken using the following
methods?
Oral: 36 -37.2C
Axilla: 36-37C
Tympanic: 35.5-37.6C
When is an oral temperature contraindicated?
Take the patient's temperature by the oral route if the following are met.
(1) The physician or nurse did not order that the temperature was to be taken by
another method (that is, did not specify rectal temperature or axillary temperature).
35
(2) The patient is conscious and can follow directions, especially the direction "don't
bite down."
(a) If a patient "bites down" on a glass thermometer, he could break the thermometer.
A broken glass thermometer could cut the patient's mouth and lips. In addition, he
could swallow broken glass and mercury.
(b) If a patient "bites down" on an electric thermometer probe, he could damage the
probe, and he could be injured by the damaged probe.
(3) Make sure the patient can breath through his nose.
(4) There is no condition present to which make it undesirable to take the patient's
temperature orally
(http://www.waybuilder.net/sweethaven/medtech/vitals/default.asp?iNum=0204)
Define the following terms:
Pyrexia: Abnormal elevation of body temperature
Hypothermia: Subnormal temperature of the body
Febrile: Marked or caused by fever
Afebrile: Not marked by fever
(http://www.merriam-webster.com/medical)
Body temperatures can be assessed by:

1. Electronic Thermometer
2. Temperature sensitive patch/tape
3. Tympanic thermometer
Pulse
Define pulse : A regularly recurrent wave of distension in arteries that results from
the progress through an artery of blood injected into the arterial system at each
contraction of the ventricles of the heart.
(http://www.merriam-webster.com/medical/pulse)
The number of pulsations in one minute is recorded. The average pulse for an adult
is 80. The range is 60 - 100.
A pulse may be felt in the following areas, describe each:
Temporal: palpated in front of the ear
Carotid: palpated at the front of the neck
36
Apical: at the apex of the heart
Brachial: palpated in the antecubital fossa at the elbow joint
Radial: palpated in the wrist just above the thumb
Femoral: palpated in the inguinal area
Popliteal: palpated at the back of the knee
Dorsalis Pedis: palpated on the anterior surface of the foot
When recording the number of pulsations rate the following characteristics are also
noted:
1. Rhythm and Strength
Define the following terms related to rhythm and strength:

Arrythmia: An arrhythmia is an irregular heartbeat - the heart may beat too fast
(tachycardia), too slowly (bradycardia), too early (premature contraction) or too
irregularly (fibrillation). Arrhythmias are heart-rhythm problems - they occur when the
electrical impulses to the heart that coordinate heartbeats are not working properly,
making the heart beat too fast/slow or inconsistently.
(http://www.medicalnewstoday.com/articles/8887.php)
Thready: A state of weak pulse that comes and go.
Bounding: A state of strong pulse at full.
2. Rate
Define the following variation in rate:
Bradycardia: in the context of adult medicine, is the resting heart rate of under 60
beats per minute (BPM), although it is seldom symptomatic until the rate drops below
50 BPM. It sometimes results in fatigue, weakness, dizziness and at very low rates
fainting. A waking heart rate below 40 BPM is considered absolute bradycardia.
(http://en.wikipedia.org/wiki/Bradycardia)
Tachycardia: Tachycardia is a heart rate that exceeds the normal range. A resting
heart rate over 100 beats per minute is generally accepted as tachycardia.
Tachycardia can be caused by various factors which often are benign. However,
tachycardia can be dangerous depending on the speed and type of rhythm. Note that
if it is pathological, a tachycardia is more correctly defined as a tachyarrhythmia.
(http://en.wikipedia.org/wiki/Tachycardia)
Palpitation: Palpitation is an abnormality of heartbeat that ranges from often

unnoticed skipped beats or accelerated heartrate to very noticeable changes
accompanied by dizziness or difficulty breathing. Palpitations are common and occur
in most individuals with healthy hearts. Palpitations without underlying heart disease
37
are generally considered benign. However, heart palpitations can be symptoms of
illnesses such as coronary heart disease, asthma, or emphysema.
(http://en.wikipedia.org/wiki/Palpitation)
(http://www.youtube.com/watch?v=k27S5j48IZw)
Respiration
Define respiration: The process of inhaling and exhaling. Human beings inhale fresh
oxygen and exhale foul carbon dioxide.
Respiration (external) is stimulated by increases carbon dioxide in the blood. The

chemoreceptors in the aorta and carotid arteries monitor the carbon dioxide. When
there is an increase an impulse is transmitted to the respiratory centre in the medulla
and a message is sent to increase the rate and depth of respirations.
Respirations are characterised in THREE different ways.
1. Rate = the number of respirations in one minute. The average for an adult is
12 - 20.
Define the following terms relating to respiratory rate:
Tachypnoea: In human beings, it is a condition of rapid breathing. Rate more than 20

per minute is considered as Tachypnoea.
Bradypnea: Refer to slow breathing rate. So anything slower than 12 per minutes is
considered Bradypnea.
Cheyne Stokes: is an abnormal pattern of breathing characterized by progressively

deeper and sometimes faster breathing, followed by a gradual decrease that results
in a temporary stop in breathing called an apnea.
(http://en.wikipedia.org/wiki/Cheyne-Stokes_respiration)
2. DEPTH = the depth of the breath e.g. shallow to deep. Define the following
terms relating to depth:
Apnoea: cessation of breathing for an indeterminate period.
Dyspnoea: this term implies conscious perception of "air hunger" or a sense of

shortness of breath, and is subjective in nature. This term is not ideal to use in
reference to veterinary patients, as they cannot relay this sense or perception of
respiratory difficulty.
Hypoventilation: ventilation that does not meet metabolic demands; by definition,

ventilation that results in a PaCO2 > 45 mmHg at sea level [38 mmHg in Fort Collins]
(hypercapnia, hypercarbia, ventilatory failure).
38
(http://www.cvmbs.colostate.edu/clinsci/wing/trauma/dyspnea.htm)
3. The characteristics of breathing are also observed.
Define the following terms describing characteristics:
Stridor: Stridor is an abnormal, high-pitched, musical breathing sound caused by a

blockage in the throat or voice box (larynx).
(http://www.nlm.nih.gov/medlineplus/ency/article/003074.htm)
Wheeze: Wheezing is a high-pitched whistling sound during breathing.
(http://www.youtube.com/watch?v=YG0-ukhU1xE)
Rhonchi: A coarse rattling sound somewhat like snoring, usually caused by secretion
in a bronchial tube
Weight
List 3 reasons for weighing clients
Three main principles form the basis of why we should weigh patients:
 to monitor the extent of loss in organ function

 to judge the effectiveness of medications (mainly diuretics);
 And to enable calculation of medication dosage.
(http://www.nursingtimes.net/whats-new-in-nursing/acute-care/nurses-must-
ensure-patients-are-weighed-on-admission-to-hospital/5003851.article)
Important points to note when weighing clients:

 Weigh in the same clothes
 Preferably at the same time of day (usually before breakfast)
 Weigh on the same scales
 Calibrate the scales if necessary
 Note the weight when the client is still
 Establish the reason for weighing
Where is the weight recorded?
In the hospital, Nurses record the weight on the Case file (on admission) and fluid chart
mainly. In the emergencies, when patient transfers to the emergency department It needs to
be recorded on the documents.
List other factors influence a person’s temperature:
39
 Fever
 Cold
 Infections
 Drugs and medication
 Alcohol
 Smoking
 Physical stress
 Emotional stress
 Sleep disturbance
(http://www.fertilityfriend.com/Faqs/Factors-that-affect-temperatures-.html)
List factors that influence a person’s pulse:
 Fitness level
 Age
 Gender
 Cardiac output
 Race
 Diet
List factors that influence a person’s respirations:
Respiratory rate is how fast or slow a person is breathing. Many things can affect a
person's respiratory rate including exercising, sleeping, strenuous activities and
certain medications, as well as drugs and alcohol.
(http://www.ask.com/question/factors-that-affect-respiratory-rate)
As nurses, we take blood pressures frequently. A blood pressure gives us an insight

into how effectively the cardiovascular system is working. Blood pressure that is too
high or too low can be early indicators of illness. It is therefore essential that you be
able to take a blood pressure accurately and interpret the results.
Define the following terms:

Blood pressure: is the pressure exerted by circulating blood upon the walls of blood
vessels.
Systolic blood pressure: Amount of pressure blood exerts on arteries while the heart
is beating.
Diastolic blood pressure

Factors controlling blood pressure are:
 Cardiac output
 Blood volume
 Elasticity of the arteries
 Size of the arterioles
e.g. a) vasodilation decreases the pressure
40
b) vasoconstriction increases the pressure
Explain why each of these would affect the blood pressure.
Cardiac output:
The volume of blood discharged from the ventricle (or the heart) per minute is called
the cardiac output. It is calculated by multiplying the stroke volume by the heart rate
in beats per minute.
Formula: Cardiac output = stroke volume x heart rate
Units: ml of blood/minute = ml of blood/beat x beats/minute
The blood pressure in your body usually changes in response to changes in cardiac
output. In other words, as the cardiac output increases, so does the blood pressure.
If the cardiac output decreases, so does the blood pressure.
(http://www.nsbri.org/humanphysspace/focus2/arterial-bp.html)
Blood volume:
When there is a greater volume of fluid, more fluid pass against the walls of arteries
resulting in higher blood pressure. If there is a less volume, it means less pressure.
(http://www.winona.edu/biology/adam_ip/misc/assignmentfiles/cardiovascular/Fact_
Aff_Blood_Pressure.pdf)
Elasticity of the arteries:
A healthy elastic artery expands, absorbing the shock of systolic pressure. The
elastic recoil of the vessel then maintains the continued flow of blood during diastole.
(http://www.winona.edu/biology/adam_ip/misc/assignmentfiles/cardiovascular/Fact_
Aff_Blood_Pressure.pdf)
Size of the arterioles
The greatest change in blood pressure and velocity of blood flow occurs at the
transition of arterioles to capillaries. This reduces the pressure and velocity of flow for
gas and nutrient exchange to occur within the capillaries. The more the size, the
more blood will flow.
(http://en.wikipedia.org/wiki/Arteriole)
Other factors affecting the blood pressure are:

 Age
 Exercise
 Emotion/Stress
 Size of the cuff
41
 Frequency of the recording
 Health status
What size cuff should be used?
We measured blood pressure differences by cuff size in 181 adults aged 25 to 74

years, allocated to a random sequence that involved the measurement of blood
pressure using a small cuff, a large cuff, and an appropriate cuff as determined by
standardized arm circumference measurement. Systolic and diastolic blood pressure
was underestimated by 3-5 mm Hg in men and 1-3 mm Hg in women when the cuff
was one size larger than appropriate. Systolic and diastolic blood pressure was
overestimated by 2-6 mm Hg in men and 3-4 mm Hg in women when the cuff was
one size smaller than appropriate. In addition, 30-40% of subjects were
"misclassified" when blood pressure cut points were used to define hypertension.
(http://www.ncbi.nlm.nih.gov/pubmed/2054405)
Where the cuff should be placed?
The inflatable part of the blood pressure cuff should cover about 80 percent of the
circumference of your upper arm. The cuff should cover two-thirds of the distance
from your elbow to your shoulder.
(http://www.mayoclinic.com/health/blood-pressure-cuff/AN01926)
How does age influence blood pressure?
Blood vessels become less elastic with age. The "average" blood pressure increases
from 120/70 to 150/90 and may persist slightly high even if treated. The blood
vessels respond more slowly to a change in body position.
(http://www.nlm.nih.gov/medlineplus/ency/imagepages/8693.htm)
Does blood pressure increase or decrease with stress?
Stress increases the blood pressure.
What is the normal range for an adult blood pressure?
Systolic 100-120mmHg and Diastolic 60-80mmHg.
Remember that the normal range is an average and does not mean that if you have a
blood pressure of 90/58 mm/Hg that there is a problem. Also if you are 70 years of
age with a blood pressure of 150/85 mm/Hg there is probably no cause for concern.
An increase on the diastolic pressure is often more significant because this may
42
indicate a disease state. It is important to record a base line and then assess
readings accordingly e.g. a person who is admitted with a blood pressure of 150/75
mm/Hg that drops to 110/70 mm/Hg must be checked and reported immediately.
Define the following terminology associated with blood pressure.

Hypertension:
High blood pressure (hypertension) means that your blood is pumping at a higher
pressure than normal through your arteries.
(http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Hypertension_mean
s_high_blood_pressure)
Hypotension:
Low blood pressure (Hypotension) means that your blood is pumping at a lower
pressure than normal through your arteries.
Korotkoff sounds:
arterial sounds heard through a stethoscope applied to the brachial artery distal to
the cuff of a sphygmomanometer that change with varying cuff pressure and that are
used to determine systolic and diastolic blood pressure
(http://www.merriam-webster.com/medical/korotkoff%20sounds)
Name the equipment needed to take a blood pressure:
Sphygmomanometer is required to note a blood pressure.
It is very important to know usual ranges of vital signs and what to do if they alter or
are outside of normal parameters.
If you observe changes who do you report these situations of risk to?
If this situation occur, I will document the readings and report to the Nurse Manager
or Register nurse available.
Where do you document vital signs and changes to vital signs?
Patient Progress notes and Adult observation Chart.
Other patient/client activity is also reportable such as changes in independence, pain

tolerance and behaviour.
Where would you record and who would you report changes in condition/
baseline data to?
I will record the changes in the Patient’s progress notes and report them to Nurse Manager
available on the shift.
43
You will have completed your first aid certificate by this stage of your course, so you
should be competent with performing cardiopulmonary resuscitation (CPR) by now.
However, it is important to understand that CPR in an uncontrolled emergency
situation is a little different than CPR that is performed in a controlled hospital setting.
Your first actions when discovering someone that you think has had a cardiac or
respiratory arrest remains the same – DRABC.
Describe what this means:
D = Danger (Look around and make sure area is safe)

R = Response (See if Patient is responding by asking them if they are okay?)
A = Airways (Clear the airways)
B= Breathing (Listen if Patient is breathing)
C= Circulation (Check circulation)
How do you summon help in a hospital?
I would call Medical Emergency team as soon as possible.
What role cans an enrolled nurse play in a cardiac arrest situation?
In the Cardiac arrest emergency, Enrolled nurse can help by calling Ambulance
number and providing the first aid. It is also Enrolled nurse responsibility to
accompany the patient all the time and let Register nurse know as soon as
possible.
Another patient on your ward talks to you about their illness and their wish not to be
revived if they require resuscitation. How would carry out the patients wishes?
As an Enrolled nurse, In this situation I can only help the patient out by reporting an
issue to Register Nurse and putting Patients request in his/her progress notes.
Who order would order a ‘do not resuscitate order’?
A Senior medical team of Professionals will order a “do not resuscitate order” for the
Patient.
44
Element 7
Prepare the client for discharge in consultation/

collaboration with a registered nurse
Chapter 24 – Tabbner’s Nursing Care
Review this chapter then complete the exercise below (see page 332)
Mr D’Arcy, aged 66, has emphysema and is admitted to your health facility often. While
talking to him you discover he is homeless and spends nights in a refuge.
What do you need to consider before discharging Mr D’Arcy?
Emphysema is a type of lung disease that causes shortness of breath. Many people
with emphysema also have chronic bronchitis. Most cases of emphysema are
caused by cigarette smoking or long-term exposure to certain industrial pollutants or
dust. Complications of emphysema can include pneumonia, collapsed lung and heart
problems.
(http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Emphysema)
In the given situation, I have to play an important role to make sure Mr D’Arcy doesn’t face
any social or financial problems as he is already affected by a serious health disease. In
order to help the Patient I will:
 Report the situation to the Register Nurse and discharge the patient only if safe to do
so.
 Try to involve an Social Organisation to help Mr D’Arcy financially as he is homeless
and may not support his health finances
 Involve a Support worker to provide moral support to the Client
 Involve an agency to help Mr D’Arcy finding an accommodation as soon as possible. I
will make sure that accommodation is at the peaceful and safe area as pollution could
be dangerous to his current lung condition
 Let his family or next to kin know as soon as possible
 Help him providing a Carer who could assist him with his daily tasks and accompany
him 24/7 as it could be harmful to leave a patient by their own.
 Provide him with all the medications prescribe and write down the procedure to take
them including timing.
 I will take Patient’s consent in the whole procedure
 Try to involve a case manager who could supervise Mr D’Arcy case and assist him
with the financial, social and medical sides.
Element 8
45
Evaluate nursing care provided
While on practicum you will have the opportunity to evaluate your own contribution to
nursing care in consultation/ collaboration with clients and registered nurses.
You will evaluate implementation of plans of nursing care in consultation/ collaboration with
a multidisciplinary team in light of potential and actual outcomes.
You will experiences will help you to understand implications and risks related to alterations
in normal physiological functioning and hospitalisation and you will have opportunities to
report and document all aspects of nursing care provided.
References
46
Crisp, J., & Taylor, C. (2005). Potter & Perry’s fundamentals of nursing (2nd ed.). Sydney:
Mosby
Funnell, R., Koutoukidis, G., & Lawrence, K. (2005). Tabbner’s Nursing Care: Theory and
Practice (5th ed.). Sydney, Australia: Elsevier.
Mosby’s Medical, Nursing and Allied Health Dictionary (2001). (6th ed.). St Louis:
Mosby.
Porth, C. M. (2002). Pathophysiology: Concepts of altered health states (6th ed.).
Philadelphia: J. B. Lippincott.
47
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HLT51607 Diploma of Nursing (Enrolled/ Division 2 Nursing)

HLTEN504B Implement and evaluate a plan of nursing care

Establish and maintain therapeutic relationships with clients

It is very important as a nurse to promote therapeutic relationships between nurse and

Please read this scenario and answer the following questions:

1. It’s very important to determine client’s nursing needs and do a required

Appendectomy (appendicectomy) is surgery to remove the appendix. The

Before implementing nursing interventions what are you going to explain

How could you establish and maintain a safe environment using

It’s important to maintain a safe environment. It can be done by using

Chapter 37 of Tabnner’s Nursing Care (pp. 606 – 631)

Remember, resistance to injury of the skin and mucous membranes

Which group/s do you think are most at risk of skin breakdown?

 People with Poor nutrition

Showering or bathing is a good opportunity for a nurse to conduct a thorough

Principles involved in shaving a client:

 Pre-plan and place the equipment on the best location available

(Tabbners Page 409)

Describe 2 conditions that affect the oral cavity

Before you commence feeding someone there are a number of points to

 Preparing the client by:

Other points to remember:

In this situation, I would consult with Dietitian who is experts in food/Nutrition

DYSPHASIA refer to difficulty in communicating

(Tabbner Page - 787)

What can you do to assist someone who has swallowing problems?

- Providing meals comprised of thickened fluids

(Tabbner Page – 658)

Give definitions for the following words that relate to elimination:

SUPPOSITORY: A drug delivery system that is inserted into the rectum,

CATHETER: is a thin tube extruded from medical grade materials serving a

APERIENT: A drug used to relieve constipation.

DIURETIC: is any substance that promotes the production of urine.

 Urinary incontinence (leaking urine or being unable to control when you

What is a suprapubic catheter?

List five nursing actions that could be implemented to prevent a client

(Tabbners Page 687-689)

(Tabbner Page: 546)

Why would you complete a bowel chart for a patient?Explain 2 reasons

why you need to be accurate in your documentation

It is a legal requirement. Also, it is a way of communication between medical

Please review pages 510 – 516 in your Tabbners “Alternative methods to

Give 2 examples when enteral feeding may be required

(Tabbners Page - 661)

How do you check the tube position?

Tube position can be checked by these 3 methods:

Aspirate Appearance: This method involves assessing the appearance of

Chapter 40 in Tabbner’s Nursing Care, the section Factors affecting

A cough can be described as productive or non-productive. Explain the

(Tabbners Page: 494)

Infective respiratory disorders are very common – everyone has experienced

Encouraging clients to practice deep breathing and coughing facilitates lung

First thing you will do as a nurse is to place client in a sitting position to

Coughing exercise is done by placing client in a sitting position and

(Tabbners Page: 514-516)

 Make sure that suction catheters remain sterile.

(Tabbners Page 511)

Name 2 different sorts of artificial airways.

(Tabbners Page: 519)

95% and more

(Tabbners Page: 319-320)

Why is oxygen therapy prescribed?

Oxygen can be administered via: