DTH107 Determine Health Assessment 1: Case Study – Care Action Plan

Assessment 1 Care Action Plan

STUDENT NAME Add your full name

DATE Enter date here

Course HLT54115 Diploma of Nursing
Subject Title DTH107 Determine Health
Unit of Competency HLTAAP003 Analyse and respond to client health information
Performance Criteria, PC: HLTAAP003: 1.1-1.4, 2.1-2.3
Knowledge and
PE: HLTAAP003: 1
Performance Evidence
Assessed KE: HLTAAP003: 1, 2a-c, 3a-m, 4a-b, 5, 6, 7, 8, 9, 10, 12, 13a-c, 14a-c
Title of Assessment Task Assessment 1: Case Study
Length 1500 words +/- 10%
Submission Due by 11:55pm AEST Sunday end of Module 3.2 (Week 6).

For this assessment, students must view two (2) case studies and respond to a care action plan for each
one. This action plan requires analysis and care planning, and is based on the following diagram.

06.10.19 Version 2 RTO Code 02469. Think: Colleges Pty Ltd. CRICOS Provider No. 00246M Page 3
Care Action Plan: Scenario 1

For this action plan, students must view case study 1, and follow this step to determine how to manage
Rob’s issues. His specifications are noted here.

Name: Rob Carrington  Married

Gender: Male  Occupation – Delivery driver
Ethnicity: Caucasian  Earns good money
Australian  Travels a lot
Aged: 53 years  Overweight 135kg
Family Status: Father  Likes TV and beer to cope with stress
Religion: Anglican  Has Type II Diabetes needing close management for job
 Smoker
 Diet preferences are ‘Convenience’
 Unknown social support and external interests
 Has osteoarthritis in L) knee

The steps in the action plan for Rob Carrington are listed on the following pages. At each step, there are a
number of questions you must respond to. Questions 1-14 relate to Rob’s situation.

Read these questions and take note of the information or actions that need to be addressed at each step.
Then, respond in the spaces provided.
 Step 1 Definition of Health Disorder

Rob has presented with a number of issues and symptoms; some of which are acute,
Question 1 some of which are chronic. In the table below, list which items are either chronic or
acute.
Acute Issue Chronic Issue
Shortness of breath Type II diabetes

Tight chest Osteoarthritis

Pain in left arm and back Obesity

Of Rob’s issues, which should be dealt with first; acute or chronic? Explain why in 50
Question 2
words.
Acute issue should be dealt first because

List five (5) body systems that are affected by Rob’s situation, and briefly note their
Question 3
purpose or function.
The five body systems that are affected by Rob’s situation are:
 Respiratory system
Respiratory system supplies oxygen to all the parts of your body and accomplishes breathing by inhaling oxygen-rich
air and exhaling air filled with carbon dioxide, which is a waste gas.

 Endocrine system
Endocrine system consists of glands that produces and secretes hormones (chemical substances) throughout the
body, to regulate the activity of the cells and organs. These hormones are responsible for physical growth,
metabolism and sexual development and functions.

 Cardio-vascular system
Cardio-vascular system also known as circulatory system permits blood circulation in the human body, transporting
oxygen, nutrients, carbon dioxide, hormones and blood cells to and from the different organs of the body.

 Muscular skeletal system

Muscular skeletal system allows the movement of the limbs and human body using two main connective tissues-
Ligaments and tendons.

 Nervous system
The nervous system is an overly complex part of the human body that allows different body parts to communicate
with each other by using both electrical and chemicals signals. This includes transmitting sensory information and
coordinate actions for any change detected that impacts the human body.
 Step 2 Normal Anatomy and Physiology

For three (3) of the body systems affected by Rob’s issues, list two (2) signs or symptoms that
Question 4
might indicate there might be a variation from normal function.

The body consists of different levels of structural organization and complexity. In 100
words, describe how each of the following items combine to make up the human body.
In your response, specify what the different types of muscle tissue are and how human
body systems are formed at a cellular level.
 Atoms
Question 5
 Molecules
 Cells
 Organs
 Muscle tissue
 Human Body systems
Response...
 Step 3 Physiology

For each body system below, describe:

 One (1) disorder or disease that may affect it
 The pathophysiology of the disease associated with the body system (20 words
Question 6 each system)
 The impact of the disease on the body system and their related structures in
relation to potential impact of specific health procedures provided (30 words
each).
Body System Potential Disease Pathophysiology of Disease Impact of disease on body system
Response... Response... Response...

Endocrine system

Response... Response... Response...

Musculoskeletal
system

Response... Response... Response...

Special Senses

Response... Response... Response...

Nervous system

Response... Response... Response...

Respiratory
system

Response... Response... Response...

Cardiovascular
system

George has type 2 diabetes. In 50 words discuss the process of carbohydrate

Question 7 metabolism, including your understanding of anabolism and catabolism.

Carbohydrate metabolism refers to the biochemical processes responsible for the formation, breakdown and interconversion
of carbohydrates in living organisms that ensures constant supply of energy to living cells.
 Step 4 Diagnostic Tests

List three (3) methods you could use to diagnose or assess Rob’s abnormalities, and
Question 8
briefly describe each one.
Response...
 Step 5 Prognosis

In 150 words, define the disorders Rob has. In your response, include the variations and
Question 9 abnormalities which would be found in each body system it affects, and any the
implications of any contraindications that might arise.
Response...
 Step 6 Conservative Medical Care vs. Surgical Intervention

Rob may need both conservative medical and surgical treatment. For each intervention
(medical and surgical) specify:
 What the impact would be to Rob (20 words)
Question 10  One (1) relevant pharmacological process and one (1) drug action
 One (1) potential indication and one (1) potential contraindication
 The role of one (1) member of the interdisciplinary team that might be required
 One (1) limitation of each member
Medical Treatment Surgical Treatment
Response... Response...

Impact to Rob

Response... Response...
Pharmacological
process and drug action

Response... Response...

Indication and
contraindication

Response... Response...
Interdisciplinary team
member role

Response... Response...

Limitation of
interdisciplinary team
member
 Step 7 Nursing Care Plan

Based on your analysis of Rob’s health information, you must now prepare a nursing
care plan that demonstrates your understanding of appropriate care and consideration
of his needs.
Question 11
Fill in the template below, noting four (4) issues Rob has and how you will manage each
one. Do not complete the final column (Discharge Plan), as it will be clarified in Step 9.
Nursing Care Plan
Nursing Diagnosis Actual Potential Implementation Expected Outcomes Discharge
(Note the issues you (How has that issue (What additional (How should it be treated?) (What do you expect Plan
have diagnosed in manifested?) issues or after treatment?)
Rob) contraindications or
complications should
be considered?)
Response... Response... Response... Response... Response...

Response... Response... Response... Response... Response...

Response... Response... Response... Response... Response...

Response... Response... Response... Response... Response...

 Step 8 Potential Complications

In addition to the abovementioned contra-indications, describe the effects of biological

Question 12 maturation and ageing processes on the body systems related to Rob’s situation, and
how they may impact the care plan provided (150 words).
Ageing causes the loss of bone mass or density with the loss of calcium and other minerals. This causes the joints to be less
flexible and stiffer, causing movements to slow down and become limited.

Ageing also has adverse effect on our respiratory system. Due to the changes in bones and muscles, the level of oxygen
present in the body may be lower. Similarly, less carbon dioxide may be discharged from the body as the muscles and tissues
present in the airways may lose the ability to remain open. Furthermore, these changes may allow air to get trapped in the
lungs causing numerous breathing problem such as shortness of breath. This will give problems to Rob to follow up on care
plan such as exercise.

To conclude, biological maturation and ageing process on the body systems has great effects in this situation of Rob’s
recovery.

Rob has suffered a cardiac arrest. In 50-75 words explain the major types of cardiac
Question 13 adaptation, what is required for cell and tissue survival, and how this may effect Rob’s
Cardiac tissue.
Response...
 Step 9 Discharge Planning

Discharge planning should form part of a care plan. For the four (4) issues you specified
in Step 7, provide a discharge plan that includes:
 The appointments that should be made for the client upon discharge
Question 14  The information or documentation that should be provided
 The healthcare professionals who should be involved.

Do not fill in the greyed-out boxes.

Nursing Care Plan
Nursing Diagnosis Actual Potential Implementa Expected Discharge Plan
(Note the issues you tion Outcomes (List what should be done to prepare the client for
have diagnosed in discharge)
Rob?)
Response... Response...

Response... Response...

Response... Response...

Response... Response...
Acute Care Action Plan: Scenario 2

For this action plan, students must view case study 1, and follow this step to determine how to manage
care for Fei Hong.

Name: Fei Hong  Chinese background

Gender: Female  Speaks little English
Ethnicity: Chinese  Came to Australia to help daughter raise her son
Aged: 60 years  Is beginning to demonstrate signs of dementia
Family Status: Kim’s  Interferes in parenting
mother (Granny)  Dictates cooking must be Asian
Religion: Buddhist.  Has hearing and sight impairment

The steps in the action plan for Fei Hong are listed on the following pages. At each step, there are a number
of questions you must respond to. Questions 15-26 relate to Fei’s situation.

Read these questions and take note of the information or actions that need to be addressed at each step.
Then, respond in the spaces provided.
 Step 1 Definition of Health Disorder

Fei has presented with a number of issues and symptoms; some of which are acute,
Question 15 some of which are chronic. In the table below, list which items are either chronic or
acute.
Acute Issue Chronic Issue
Confusion Potential early
signs of
dementia
Had bit of Hearing
cold lately impairment
Constipation Cognitive
impairment
Dehydration Sight
impairment
Unsteady on
her feet
Fatigue, loss
of appetite

List four (4) body systems that are affected by Fei’s situation, and note their purpose or
Question 16
function.
The 4 body systems that are affected by Fei’s situation are as follows:
 Step 2 Normal Anatomy and Physiology

Explain the effect Fei’s biological maturation might have had on three (3) of her body
Question 17 systems. For each body system, specify two (2) signs or symptoms that might indicate
they might not be functioning normally.
Response...

In 50 words, describe homeostasis and the relationship between homeostatic imbalance

Question 18
and disease.
Response...
 Step 3 Physiology

For each body system below, describe:

 One (1) disorder or disease that may affect it
 The pathophysiology of the disease associated with the body system (20 words
Question 19 each system)
 The impact of the disease on the body system and their related structures in
relation to potential impact of specific health procedures provided (30 words
each).
Body System Potential Disease Pathophysiology of Disease Impact of disease on body system

Urinary System Response... Response... Response...

Lymphatic System Response... Response... Response...

Special Senses Response... Response... Response...

Digestive system Response... Response... Response...

Integumentary
Response... Response... Response...
system

Reproductive
system
Response... Response... Response...

Immune system Response... Response... Response...

 Step 4 Diagnostic Tests

List three (3) methods you could use to diagnose or assess Fei’s abnormalities, and
Question 20
briefly describe each one.
Response...
 Step 5 Prognosis

In 200 words, define the disorder Fei has. In your response, include the variations and
Question 21 abnormalities which would be found in each body system it affects, and any the
implications of any contraindications that might arise.
Response...
 Step 6 Conservative Medical Care vs. Surgical Intervention

Fei should receive conservative medical treatment for her issue. For this
intervention provide responses to the points below, considering the effects on
Fei based on her age:
 What the impact would be to Fei (20 words)
Question 22  One (1) relevant pharmacological process and one (1) drug action
 One (1) potential indication and one (1) potential contraindication
 The role of one (1) member of the interdisciplinary team that might be
required
 One (1) limitation of each member
Impact to Fei Response...

Pharmacological process
Response...
and drug action

Indication and
Response...
contraindication

Interdisciplinary team
Response...
member role

Limitation of
interdisciplinary team Response...
member

In 50 words explain the process of osmosis including osmotic and hydrostatic

Question 23
forces.
Response...
 Step 7 Nursing Care Plan

Based on your analysis of Fei’s health information, you must now prepare a nursing care
plan that demonstrates your understanding of appropriate care and consideration of his
needs.
Question 24
Fill in the template below, noting four (4) issues Fei has and how you will manage each
one. Do not complete the final column (Discharge Plan), as it will be clarified in Step 9.
Nursing Care Plan
Nursing Diagnosis Actual Potential Implementation Expected Outcomes Discharge
(Note the issues you (How has that issue (What additional (How should it be (What do you expect Plan
have diagnosed in Fei) manifested?) issues or treated?) after treatment?)
contraindications or
complications should
be considered?)
Response... Response... Response... Response... Response...

Response... Response... Response... Response... Response...

Response... Response... Response... Response... Response...

Response... Response... Response... Response... Response...

 Step 8 Potential Complications

Fei has had a UTI and ketones were present in her urine. In 50 words, explain the
Question 25
process of renal acidosis /alkalosis and what effect this has on the pH of the blood.
Response...
 Step 9 Discharge Planning

Discharge planning should form part of a care plan.

For the four (4) issues you specified in Step 7, provide a discharge plan that includes:
 The appointments that should be made for the client upon discharge
Question 26
 The information or documentation that should be provided
 The healthcare professionals who should be involved.

Do not fill in the greyed out boxes.

Nursing Care Plan
Nursing Diagnosis Actual Potential Implementa Expected Discharge Plan
(Note the issues you tion Outcomes (List what should be done to prepare the client for
have diagnosed in discharge)
Fei)
Response... Response...

Response... Response...

Response... Response...

Response... Response...
 Additional Health Information Knowledge

Questions 27-29 are not specifically linked to the care action plans you completed above. However, they
relate to a range of healthcare information that you, as a healthcare professional should know in order to
provide appropriate care to you clients.

For each of the issues below:

 Give an example of what the issue could be
Question 27
 Note two (2) body systems that could be affected
 Explain the impact on each body system
Issue Example Two (2) Affected Body Systems Impact on Body System
Response... Response... Response...
Diving emergency

Response... Response... Response...

Tissue damage

Response... Response... Response...

Altitude emergency

Temperature Response... Response... Response...

exhaustion
emergency
Response... Response... Response...
Overdose or
poisoning Emergency

Response... Response... Response...

Skin penetration
wound

Response... Response... Response...

Blunt object wound

In 20 words, for each response, address the below points:

 Explain the difference between molecules and compounds
 Describe metabolism and the two processes it involves
Question 28
 What is pH?
 How does respiratory acidosis occur?
 What is alkalosis and how is it prevented?
Point to Address Response

Molecules and compounds Response...

Matabolism Response...
pH Response...
Respiratory acidosis Response...
Alkalosis Response...
 For each of the body processes described below, specify the type of transport it relates
to, using this list.
 Passive-Simple diffusion
Question 29  Active transport
 Passive- Facilitated diffusion
 Osmosis
 Hydrostatic pressure
Type of Transport Process

Response... The passage of water molecules down the concentration gradient across a semipermeable membrane.
Sodium potassium pump: The movement of sodium ions from a lower concentration inside the cell to a
Response... higher concentration outside the cell, with the assistance of ATP.
Cellular metabolism requires glucose, a large molecule. The cell provides glucose-specific carrier proteins
Response... that bind to glucose molecules and allow them to enter the cell from a higher to lower concentration.
Gas exchange at the alveoli: Oxygen is exchanged from the air to the blood and carbon dioxide from blood to
Response... air.
Response... The force exerted by blood against the walls of the blood vessels by the pumping action of the heart.