Locations of falls seen in the facility

Enrolled Nurses, under the direction and supervision of a registered nurse, implement preventative, curative and rehabilitative nursing care in hospitals, aged-care facilities, the community or other health care settings.

Comprehensive knowledge and skills are required for collecting, using and documenting information about a person’s health care, clinical problem-solving and decision-making and applying evidence to the planning and evaluation of nursing care. In this unit you will integrate the knowledge and skills you have developed throughout your studies, establishing the foundation for successfully transitioning into the role of a beginning enrolled nurse capable of providing safe, competent, holistic nursing care.

Identify and analyse situations of risk associated with nursing care while applying health education principles and demonstrating an understanding of harm minimisation

Using a problem solving approach, analyse a client from a clinical placement or in the nursing home, who has had a prolonged stay due to risks which were not identified during assessment.  Demonstrate your use of critical thinking in order to suggest possible solutions that are evidenced based: (1500 words)

The nursing process is a scientific method used by nurses to ensure the quality of patient care. This approach can be broken down into five separate steps.

Assessment Phase

The first step of the nursing process is assessment. During this phase, the nurse gathers information about a patient’s psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview. Physical examinations, referencing a patient’s health history, obtaining a patient’s family history, and general observation can also be used to gather assessment data. Patient interaction is generally the heaviest during this evaluative phase.

The diagnosing phase involves a nurse making an educated judgment about a potential or actual health problem with a patient. Multiple diagnoses are sometimes made for a single patient. These assessments not only include an actual description of the problem (e.g. sleep deprivation) but also whether or not a patient is at risk of developing further problems. These diagnoses are also used to determine a patient’s readiness for health improvement and whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.

Planning Phase

Once a patient and nurse agree on the diagnoses, a plan of action can be developed. If multiple diagnoses need to be addressed, the head nurse will prioritize each assessment and devote attention to severe symptoms and high risk factors. Each problem is assigned a clear, measurable goal for the expected beneficial outcome. For this phase, nurses generally refer to the evidence-based Nursing Outcome Classification, which is a set of standardized terms and measurements for tracking patient wellness. The Nursing Interventions Classification may also be used as a resource for planning.

Risk factors associated with falls of clients

The implementing phase is where the nurse follows through on the decided plan of action. This plan is specific to each patient and focuses on achievable outcomes. Actions involved in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for follow-up. Implementation can take place over the course of hours, days, weeks, or even months.

Once all nursing intervention actions have taken place, the nurse completes an evaluation to determine of the goals for patient wellness have been met. The possible patient outcomes are generally described under three terms: patient’s condition improved, patient’s condition stabilized, and patient’s condition deteriorated, died, or discharged. In the event the condition of the patient has shown no improvement, or if the wellness goals were not met, the nursing process begins again from the first step.

Holistic health assessment is central to nursing practice.  By practicing and developing the knowledge and skills required to provide holistic nursing care you will develop confidence in understanding and responding to each client’s situation.  It is imperative that you gain consent and ensure that information is kept confidential.

Listen to the cues from your clients as these will guide and direct your nursing care.

You are to perform a holistic assessment on two clients. Attach the holistic assessment, including your nursing care plan and the evaluation to this assessment.

Holistic Skills Assessment Outline

Discharge Assessment

Observe and question client concerning their physical health status, clarify concerns about proposed interventions

Questions:

oAccess the Nursing and Midwifery Board of Australia website https://www.nursingmidwiferyboard.gov.au. Discuss the professional standards of practice, codes and guidelines for an Enrolled Nurse.

oInterview the client using the facilities admission nursing assessment form.

oComplete all questions on the nursing admission; this is to be handed in as part of your written assessment.

oWhat is the Clients medical diagnosis?

oIdentify 3 problems associated with this client’s medical diagnosis (review ADL’s)

oDoes this client understand his / her medical diagnosis?

oDoes this client have any concerns about his medical diagnosis?

oIdentify proposed medical and nursing interventions scheduled for this client?

oDoes this client understand the proposed medical and nursing interventions scheduled?

2 Nursing Care Plans Provide care as outlined in the nursing care plan under direct supervision of the Registered Nurse or Nurse Educator from Care Training Institute.

Effects of chronic or acute illness on mobility and falls risk

3 Observation Charts

Assesses your knowledge and skills in taking a BP, Temp., Resps, O? Sats, HR, Sedation Score, Pain assessment. These assessments need to be documented at least twice on two different clients.

Recognise common signs and symptoms, health problems and risk factors associated with variations from normal body functioning and health status

oWhat are the most prevalent signs and symptoms of this client’s illness?

oIdentify risk factors associated with this client acquiring this illness.

oHow has this illness affected this client’s holistic health status? Address all parameters of health. (physical, psychological, spiritual, environmental and social)

Wound Assessment

You are required to gain consent from a client to assess and dress a wound following the care plan.  Provide documentation of your care.  This needs to be done at least three times so that you can document the wound healing.

Recognise potential breakdown of skin integrity and assess wounds and risk factors associated with variations healing depending on chronic illness.

Questions:

oWhat are the most common wounds seen in your workplace?

oIdentify risk factors associated with wound assessment of clients?

oHow has chronic illness affected this client’s ability for repair and associated to nutritional requirements for holistic health status?

Waterlow Assessment

These 3 documents will asses your ability to perform a Falls Risk assessment, obtain a BGL, record it and assess a clients Waterlow Score. You must perform these assessments on two different clients in the course of this placement.

These documents can be filled out within 1 shift

Recognise potential for falls and development of pressure areas and risk factors associated with variations healing depending on chronic illness.

The fifth step of the nursing process is evaluation. Evaluate the nursing care plan.  Outcome measure may be psychosocial (quality of life, improved client perception of care, reduction in depressive and anxiety symptoms), physiologic (improved health, reduced complications), or functional improvement.  Evaluation of the process and the results may occur through client and family consultation, peer assessment, audit and self-reflection. 

7 Emergency Policies and Procedures Outline the emergency policies and procedures for this health facility.  Include emergency codes, risk, emergency trolleys, CPR, consent.  

1.Admission/discharge assessment

Question

1. a) Discuss the professional standards of practice, codes and guidelines for an Enrolled Nurse.

• Enrolled nurse should work in agreement of the law and procedures affecting the practise (Lundy 2014, pp 3-11).
• The EN should admit and be held accountable and responsible for their own actions
• Should document and report care
• EN should give nursing care that is acknowledged by research evidence

b)What is the Clients medical diagnosis?

The client is suffering from allergy

c)3 problems associated with this client’s medical diagnosis (review ADL’s)

If not treated the allergy will affect activity of daily leaving in the following ways;

• Stress during food planning due to food allergies
• Social implication- the child may be expelled from the group of friends for being different
• Living with fear and anxiety over food safety

d)Does this client understand his / her medical diagnosis?

Locations and risk factors of pressure areas in clients

e)Does this client have any concerns about his medical diagnosis?

f)Identify proposed medical and nursing interventions scheduled for this client?

Access for wheezing, shortness of breath, auscultate breath sounds, and check for the client’s sensation of a narrowed airway. Administer bronchodilators to reduce bronchospasms, epinephrine for anaphylaxis management and antihistamines (Fleischer, Spergel & Pongracic 2015, pp 29-36).

g)Does this client understand the proposed medical and nursing interventions scheduled?

2.Observation chart

Questions

a)What are the most prevalent signs and symptoms of the client illness?

The signs and symptoms include difficulty in breathing, shortness of breath, chest tightness, sneezing and high fever.

b)Risk factors associated with this client?

• Hereditary- the clients both parents have history of allergy
• Environment- the clients environment is polluted with dust, cigarette smoke and smoke

c)How has this illness affected this client’s holistic health status? Address all parameters of health. (physical, psychological, spiritual, environmental and social)

The allergy has affected the client physically by causing  high fever, chest tightness, shortness of breath and sneezing

Allergies tend to make an individual not to get some sleep, sleep deprivation can lead to mental illness, since lack of enough sleep can lead to anxiety and depression

Running nose and sneezing caused by allergy keeps the individual from going to church leading to a decrease in spiritual health.

Signs and symptoms caused by allergy can prevent an individual from interacting with others in fear of being laughed at.

3.Wound assessment

Question

a)What are the most common wounds seen in your work place?

The common wounds include diabetic wounds, surgical wounds, burn wounds and a pressure sores.

b)Identify risk factors associated with wound assessment of clients?

The risk factors include;

• Hyperglycaemia that is sugar above 150
• Limited immobility which can make the skin susceptible to damage
• Reinfection by the clients own normal flora such as staphylococcus can cause surgical wound infection (Malone and Debra 2013, pp 89-95)

c)How has chronic illness affected this client’s ability for repair and associated to nutritional requirements for holistic health status?

One of the problem associated with allergy is what we eat. If we avoid all foods that we are allergic to, we may miss the important nutrients provided by them which may lead to poor nutrition. Lack of this nutrients the body will lack energy to repair damaged body tissues and other functions of life.

4.Fall risk assessment

Question

a)What are the most common location of falls in the facility?

Common location of falls include construction sites, catering industry, trees, school and stairs.

b)Identify risk factors associated with falls of clients?

Factors increasing the risk of fall include arthritis, chronic disease burden, and muscle weakness in the elderly. Environmental hazards such as poor lightning, slippery floors and degraded pavements.

c)How has chronic or acute illness affected this client’s ability for change their mobility and increase the falls risk?

Developing a care plan and progress notes for a client

Musculoskeletal pain experienced by the individual may limit the client from moving. The client may be forced to use clutches or wheel chair which may increase the risk of falls when going up or down the stairs.

Pressure area assessment

Question

a)What are the most common location of pressure areas on clients on the facility?

Most common location include the skin that covers the bony areas such as the sacrum, heels, ankles, tail born, back of the cranium and the elbow.

b)Identify the risk associated with skin break down of clients?

Risk factors associated with skin break down include diabetes, smoking, anaemia and other vascular conditions that may decrease blood flow to all parts of the body hence causing a skin break down.

c)How has chronic or acute illness affected this client’s ability for change their mobility and increase the risk of developing pressure areas?

 Pain experienced by the individual may limit the patient from moving, when the feeling horrible effects of pressure. Too much pain may also lead to the sedation of the client causing immobility. Poor immobility may risk the patient to develop pressure ulcers especially in bony areas this due reduced flow of blood in the tissues (Butler 2015, pp.443-450).

5.Care plan and progress notes

Questions

a)What actions would an EN take in regards to referring a client for allied health services?

Enrolled nurses should ensure that:

• Permission has been granted for the transfer and should be documented
• Client’s clinical data should be available and continuing care of the patient should be provided to the receiving health facility.
• Patients with life threatening conditions have to be stabilised before the transfer.
• The enrolled nurse should ensure that the client is evaluated by the physician before transfer (Warren, Fromm & Potella 2013, pp. 256-262).

b)What are some services available at the facility that a client could be referred to?

Services available include nutritional counselling, paediatric care, family support services, mental health care, physical therapy and rehabilitation services, home nursing services and prescription services.

c)What type of documentation is required by the health care facility to refer a client for allied / or other services?

The health care facility should obtain a consent transfer that is well documented. If a client refuses to be transferred a patient refusal should be written on the transfer consent/refusal form.

A memorandum of transfer should be completed that shows the gain of transfer outweighs the risk and should be signed by the physician and the administrative representative of the facility.

d)How does the health facility implement and monitor nursing care plans?

• Ensure that the health care providers stick to the recognised professional practise
• Encourage abidance to the accreditation requirements, regulation and statuses
• Ensure reduced practised variation
• Standardise practises within the health system

6.Emergency policy and procedure

a)Outline the emergency policies and procedures for this health facility?

Physician and trained personnel to initiate an emergency procedure should be readily available. All emergency medications should all be kept in one kit that is easily movable e.g. emergency trolley and can be accessed easily. Inventory should be looked at monthly to check for expired medication and working equipment.

Health care providers should get a consent from the client before doing a life threatening procedure. If the patient is unconscious the consent can be gotten from the parents.

Cardiopulmonary resuscitation should be done to patient who is unconscious and has no pulse. CPR should not be done to a client who has ordered not to be resuscitated in case of cardiac arrest (Steve, David & Stephen 2012, pp 177-196).

References

Butler, C. (2015). Pediatric skin care: Guidelines for assessment, prevention, and treatment. Ped.Nurs, [online] 32(5), pp.443-450. Available at: https://myelitis.org/resources/skin-health-prevention-and-treatment-of-skin-breakdown/ [Accessed 3 Oct. 2018].

Fleischer, D., Spergel, J. and Pongracic, A. (2015). Primary prevention of allergic disease through nutritional interventions. The Journal of Allergy and Clinical Immunology. In Practice, 1, pp.29-36.

Lundy, K. (2014). A history of health care and nursing. Role development in professional nursing practice, [online] 34, pp.3-11. Available at: https://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/professional-standards/enrolled-nurse-standards-for-practice.aspx [Accessed 3 Oct. 2018].

Malone, M. and Debra, L. (2013). Surgical site infections: reanalysis of risk factors. Journal of Surgical Research, [online] 103, pp.89-95. Available at: https://www.sciencedirect.com/science/article/pii/S0022480401963437 [Accessed 3 Oct. 2018].

Steve, A., David, A. and Stephen, J. (2012). Clinical policy: procedural sedation and analgesia in the emergency department. Annals of emergency medicine, [online] 45(2), pp.177-196. Available at: https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=emergency+policy+&btnG= [Accessed 3 Oct. 2018].

Warren, J., Fromm, R. and Rotella, L. (2013). American College of Critical Care Medicine. Guidelines for the inter-and intrahospital transport of critically ill patients. Crit care med, [online] 32, pp.256-262. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4966347/ [Accessed 3 Oct. 2018]