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TAKE HOME EXAMINATION

SEMESTER MAY 2022

NBNS1214

NURSING HEALTH ASSESSMENT

MATRICULATION NO : 910412146165001
IDENTITY CARD NO. : 910412146165

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PART A

QUESTION 1(a)

Subjective data
1. Madam K had intermittent abdominal pain and bloating.
2. Madam K stated that the pain increased in severity over the past 9 to 10 hours.
3. Madam K developed nausea, lower back pain, and discomfort radiating into the perineal
region.
4. Madam K reports having had no bowel movement for the past two days.

Objective data
1. Blood pressure reading is 118/70mmHg.
2. Temperature taken is 38.3 ̊C.
3. Pulse reading: 92 beat per minute.
4. Respiration: 24 per minute.
5. Diagnostic evaluation - haemoglobin: 12.8g/dL, haematocrit: 37.1%,
6. Auscultation: bowel sounds are diminished.

QUESTION 1(b)

1. Actual nursing diagnoses

Problems related to Aetiology as evidence by Sign and
symptoms
1. Bowel related to No bowel as evidence by 1.Abdominal
obstruction movement for pain and
2 days. distended.
2. Nausea.
3. Lower back
pain.
2. Hyperthermia related to Bacterial as evidence by Elevated body
infection temperature
38.3 ̊C.

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2. Potential nursing diagnoses
Problems related to Etiology
1. Risk of imbalanced nutrition: related to Impaired digestion and lack of
less than body requirements absorption in the bowel.

2. Risk for activity intolerance related to Abdominal distention secondary to

bowel obstruction.

QUESTION 2(a)

Four reasons of verification data

1. To ensure that assessment information is complete.
2. To verify that linked subjective data and objective data are in agreement.
3. To get more information that may have been overlooked previously.
4. To avoid jumping into conclusion and differentiate cues and inferences. For example, cues
are subjective or objective data that can be directly observed by the nurse; that is, what the
client says or what the nurse can see, hear, feel, smell, or measure. Inferences are the nurse's
interpretation or conclusions made based on the cues.

QUESTION 2(b)

Validating assessment information

Guidelines
Compare subjective and objective data to
verify the client's statement with your
observations.
Clarify any ambiguous or vague statement
Double check the data that are abnormal
also the equipment used.
Example
Madam K had a fever need to be compared
with the measurement of body temperature.
Madam K had abdominal pain, as a nurse,
you should do pain assessment of the type,
severity, frequency of pain.
Repeat the measurement. Use another piece
equipment as needed to confirm
abnormalities or ask someone else to collect

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Identify factor that may interfere with
accurate measurement.
Be sure your data consist of cues not
inferences
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the data.
Ask Madam K whether she has taken any
hot drinks prior to taking temperature .
Observation: Madam K complain of no
bowel movement for 2 days.
Inferences: Constipation.
Action: Obtain additional information such
as nutritional status and bowel elimination
pattern.

Use references like textbook or journals to Based on sign and symptoms, etiology
explain phenomena. related could be a sign of diseases and
possible complications.

PART B

QUESTION 1: Community assessment

1. Physical environment
Before Mr. O discharged from hospital, as a nurse you have to ask the patient if his home
needs to be adapted to make it more accessible. For example, he may need a wheelchair ramp
or a stairlift. If these types of modifications are needed, the issue can be referred to the local
social care and support services.

2. Safety and transportation

Injury prevention must be prioritized due to the high prevalence of falls and extra
comorbidities that exacerbate fall risk in people who have had their lower limbs amputated
like Mr. O. All people who have had lower limb amputations should take into consideration
using devices such stiff dressings, stump protectors, and hip protectors, especially those who
are at a high risk of falling and whose risk factors cannot be modified.

In daily life, accessibility is crucial, particularly when interacting with both internal and
exterior surrounding. It is generally acknowledged that those who are disabled experience

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fewer possibilities and a lower quality of life than those who are not. Additionally, utilising a
walking aid like a wheelchair presents more hurdles and difficulties for people like Mr. O
who have poor accessibility when they travel. It's important for nurses to advise Mr. O about
accessible transportation options, including restrooms, wheelchair ramps, and even parking
spaces.

3. Health and social services

Each patient will react differently to having a limb amputated. Their coping mechanisms or
responses may alter during rehabilitation and later, and as nurses, we must be alert to
behaviours that can be cause for worry, such as denial, withdrawal, suppression, regression,
projection, and displacement. If necessary, prompt referral to the right expertise is required.

4. Communication services
An online system (i.e.. email, Google meet, team working programmes) may be set up, which
can be particularly useful for Mr. O. The management of patients with limb loss and
amputations through telerehabilitation improves the care of a difficult patient population.
This care may start with a brief inpatient rehabilitation stay after an amputation or, more
critically, during a preoperative online consultation. Telerehabilitation can be a helpful first
step in the rehabilitation process in either scenario. Telerehabilitation uses currently available
technology to deliver timely, high-quality therapeutic care that can enhance the functional
result of individuals with limb loss over the course of their lifetimes. Telerehabilitation, like
other diseases and other disciplines, can present a chance to link clinical specialists with
patients in more remote or underserved places, with the concurrent goal of lowering health
care inequities.

5. Economic levels
Determine Mr. O's financial situation before the confinement process and after the operation.
This is because those who have this operation incur the danger of losing their jobs if they lose
the affected limb. As a result, Mr. O might request aid on behalf of the group in need by
supplying information about certain welfare organizations. Mr. O may also seek aid from
SOCSO if he is still working.

QUESTION 2(a)

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How to formed a clinical pathways
1. Determine if it is appropriate
 The most important factor in determining whether a particular patient group is
suitable for pathway implementation is that their episode(s) of care have some form of
pattern and that there is a well-defined patient population.
 In surgical cases, this could entail that patients undergo their surgery followed by a
specific number of days of hospitalisation.
 In a medical issue, this may imply that individuals go through specific stages of
recovery or that the management changes at specific points. It is not required to limit
the length of the journey or to limit it to a single inpatient stay.
 Patients receiving palliative care or community rehabilitation can also use the
pathway methodology.

2. Speak with your unit manager

 An essential first step is to make sure your unit manager is behind you. The unit
manager might be able to give you some time away from the ward area to spend
creating the trail.
 Speaking with the doctors or surgeons involved and any other allied health
professionals who will have a substantial influence on the course of action may also
be a good idea at this time.

3. Contact the clinical path coordinator

 Request a meeting with the care coordination manager so you can go over each of the
steps involved. You should be able to get all the assistance you need from the care
coordination manager to get you through the procedure.

4. Follow the clinical path development plan

 This will provide you a list of all the tasks to do along with the option to establish
deadlines, which can be quite helpful to keep on schedule. The review of history in
the creation of pathways is also covered in the guide.
 Before any work is done, the plan must be discussed with the care coordination
manager.

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QUESTION 2(b)
Advantages of utilizing the clinical pathways
1. Benefits to patients
 Improved organisation and continuity of care.
 Avoidance of duplication of effort.
 Involvement of the patient in the planning of care.
 Use of evidence-based, locally-agreed best practice.
 Provision of integrated services from more than one organisation.
 Provision of a "manager" to monitor and record progress against a care pathway or
plan.
 Receipt of a printed or electronic copy of own care pathway or plan.

2. Benefits to clinicians/practitioners
 Availability of patient's record on-line for viewing.
 Capture of clinical terminology and codes to improve quality, and aid subsequent
analysis.
 Availability of the most up-to-date guidelines and best practice.
 Ability to feed into the development process to provide continual improvement.
 Ability to monitor progress along a care pathway.
 Ability to measure deviance from a care pathway with reasons for that deviance.
 Ability to integrate local and national standards.
 Ability to document by exception.

3. Benefits to healthcare managers

 Improved ability to plan and measure the use of personnel and resources.
 Ability to measure the difference between planned and actual care.
 Delivery of more standardised care, linked to protocols and treatment plans.
 Redesign of healthcare delivery is made possible, thereby avoiding safety and quality
risks posed by existing outmoded ways of working.
 Ability to continually improve care pathways.