HLTENN003 / 004 Fundamental Nursing Skills Assessment

Subject Code & Title :– HLTENN003 / 004 Fundamental Nursing Skills
Assignment Type :– Assessment
Nursing the unconscious client with a head injury can be a challenging experience.These clients have no control over themselves or their environment therefore he/she is highly dependent on the nurse.The skills required to care for the head injured unconscious client is not specific to critical care or high dependency units as these clients are nursed in a variety of clinical settings. Even though nursing these clients might be daunting it can also be very rewarding and the skills you acquire will build confidence in your ability to care of all clients.
HLTENN003 / 004 Fundamental Nursing Skills Assessment

HLTENN003 / 004 Fundamental Nursing Skills Assessment

You may think nursing these clients will be a source of stress and anxiety. How ever the knowledge and skills acquired in these two Units will provide you with the basic grounding required to under take on going assessment planning and implementation of quality care.

HLTENN003 / 004 Fundamental Nursing Skills Assessment


Mrs. XXX Waxman a 31 year old Jewish woman who has been admitted to the Neurological Ward after spending 48 hours in Intensive Care Department. She is unconscious has an intravenous line a NGT and an indwelling urinary catheter in-situ. She has been entrusted into your care

Mrs. Waxman on her return from a business trip slipped from the top of an escalator at Melbourne Airport. The fall resulted in a major head injury together with soft tissue injuries to her neck and lacerations and grazes to her arms and legs she has a deep wound on lower right leg.

HLTENN003 / 004 Fundamental Nursing Skills Assessment

Mrs. Waxman is married with three young children and her husband Martin a renowned science fiction author works from home and cares for the children.

Mrs. Waxman is employed as a computer systems analyst and manages the Australian branch of the company. She works long hours and spends a considerable amount of time overseas on business trips. Whilst on her business trips she is required to socialise with business partners and company delegates.

Her husband informs you that her Jewish culture and faith are extremely important to her.

Case Presentation
 Unconscious as a result of a head injury sustained following a fall on escalator.
 Soft tissue injuries to her neck
 Lacerations and grazes to both arms and legs
 Deep wound on the outer aspect of her lower right leg (sutured in Emergency Department on admission).
 No evidence of fractured skull on CT and X-ray

HLTENN003 / 004 Fundamental Nursing Skills Assessment

Past History :-
During her last pregnancy in 2010 she was diagnosed with Gestational Diabetes how ever this resolved after the birth of the baby. The baby’s BGL was monitored for 24 hours following delivery. Both of her other pregnancies were uneventful.

Mrs Waxman has gained 20 kilos over the past 12 months due to her long working hours and socialisation requirements. Her alcohol consumption increased with her promotions and she tends to survive on snacks and strong coffees throughout the day.

HLTENN003 / 004 Fundamental Nursing Skills Assessment

Doctor’s Orders
 Half hourly vital signs and Glasgow Coma Scale (GCS) readings until the GCS reaches 15 or as per Neurologist’s order.
 Report deterioration in GCS readings stat.
 Report any seizures STAT
 Oxygen @ 3 L/min via nasal prongs if oxygen saturation levels < 95%
 Medications as per medication chart
 6 hourly Intravenous antibiotics, daily anticoagulant S/C
 8 hourly Intravenous fluids as per Intravenous Chart
 Report urinary output < 30mls/hour
 Thigh height anti-embolic stockings to both legs
 For review in 24 hours re: introduction of nutrition via NGT if condition remains stable.

Nursing Assessment
 Unconscious, responding to painful stimuli
 GCS score 11, pupils equal and reacting to light
 Temperature 38.5 degrees Celsius,
 pulse 92 beats per minute,
 respiration rate 18 per minute
 Blood pressure static at 180 mmHg 120
 Oxygen saturation (SaO2) 97% in room air
 FWT revealed positive for Ketones, leukocytes, and blood. High level of glucose ++, reported to Registrar.
 BGL taken as ordered reading obtained 25 mmol/L. Further orders require BGL readings 6 hourly for the next 24 hours.
 Dressings attended to lacerations and grazes on arms and legs all wound are healing well however the deep wound on her lower right leg is inflamed oedematous and oozing a moderate amount of purulent discharge.
 Reddened areas noted on her sacrum and heels
 IV infusion 1 litre 0.9% NaCl 8/24, due to be changed at 1400 hours
 6 hourly IV antibiotics due at 1400 hours
 Nil drainage of abdominal contents via NGT (on free drainage), with 4 hourly aspiration.
 Indwelling catheter draining well output > 60mls/hour. Slightly cloudy straw coloured.

HLTENN003 / 004 Fundamental Nursing Skills Assessment

Assessment requirements :-
PLEASE NOTE: Students are required to pass EACH assessment requirement (questions (a) to (d) of this case study. The APA referencing system MUST be used

a) Using the information above write an admission summary using the SOAPIE format for Mrs. XXX Waxman – this must be hand written as per legal requirements.

b) Read chapter 17 of Tabbner’s – Components of the nursing Process. Read up about the nursing process writing nursing diagnoses, and care planning. Using the NANDA nursing diagnoses included do the following assessment. Watch this You tube clip to clarify.

HLTENN003 / 004 Fundamental Nursing Skills Assessment

HLTENN003 / 004 Fundamental Nursing Skills Assessment

Analyse the information provided and select four (4) identified nursing care needs client problems and goals of care and formulate a nursing care plan for Mrs. XXX Waxman. For each of these diagnoses and stated goals of care, please provide four (4) appropriate nursing interventions with the rationale for each. (½ mark for each client problem and each objective 1 mark for each nursing intervention and each rationale)

4 x care plan pages included. Please use one page per nursing problem identified.

c) Explain what physical cognitive emotional and behavioral potential long term outcomes may result from Mrs. Waxman’s head injury.

HLTENN003 / 004 Fundamental Nursing Skills Assessment

d) Explain the physiology & risks associated with the immobilized patient based under the following headings – WHAT is the condition WHY is Mary at risk?

i) Deep Vein Thrombosis
ii) Pneumonia
iii) Contractures
iv) Bowel obstruction
v) Decubitus ulcers

e) What are at least two (2) risk prevention strategies that could be implemented to prevent EACH problem?

f) Quality of writing grammar expression spelling style and the use and acknowledgment of appropriate literature and reference list will be graded. (Please refer to your handbook for guidance with referencing method.)

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