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HLTENN043 Implement and monitor care for a person with acute health
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1.
Provide a definition and two (2) possible causes for each of the following acute health conditions:
Acute health Condition
Definition
State two (2) reasons for this
condition
Cerebral Oedema
Cellulitis
Acute pharyngitis
Renal Calculi (Urinary
tract calculi)
Myocardial Infarction
Erectile dysfunction
Spontaneous Abortion
Diabetes insipidus (DI)
specifically Central
(neurogenic) DI
Gastritis
Retinal detachment
Acute Otitis Media
Meningitis
Osteomyelitis
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Brown, D. & Edwards, H. (2020) Lewis’s Medical-Surgical Nursing ANZ 5th ed. Elsevier. Australia.
Chapter: Nursing Management: Acute intracranial problems . Section: Cerebral Oedema
Chapter: Nursing Management: Coronary artery disease and acute coronary syndrome.
Chapter: Nursing Management: Male reproductive problems Section: Erectile dysfunction
Chapter: Nursing Management: Female reproductive problems. Section: Spontaneous Abortion
Chapter: Nursing Management: Endocrine problems. Section: Nursing Management: Endocrine
problems
Chapter: Nursing Management: Upper respiratory problems. Section: Nursing Management: Upper
respiratory problems
Chapter: Nursing Management: Upper gastrointestinal problems. Section: Gastritis
Chapter: Nursing Management: Visual and auditory problems. Section: Retinal detachment &
Acute Otitis Media
Chapter: Nursing Management: Musculoskeletal problems. Section: Osteomyelitis
Koutoukidis, G., Stainton, K. (2021) Tabbner’s Nursing Care Theory and Practice 8th ed. Sydney,
Australia: Elsevier.
Chapter: Nursing assessment and management of neurological health. Section: Meningitis
Chapter: Nursing in the acute care environment. Section: Cellulitis
2.
Match the conditions from list below, with the correct acute disorder in the table.
Conditions: Encephalitis, Urinary tract infection, Broken arm, Appendicitis, Urinary tract infection,
Hypoglycaemia, Otitis externa, Stroke, Chest pain, Ectopic pregnancy, Bronchitis, Dermatitis
Acute disorder
Conditions
Acute respiratory disorders
Acute cardiovascular disorders
Acute neurological disorder
Acute renal disorder
Acute gastrointestinal disorders
Acute musculoskeletal disorders
Acute central nervous system disorders
Acute reproductive disorders
Acute integumentary disorders
Acute sensory disorders
Acute endocrine disorders
Brown, D. & Edwards, H. (2020) Lewis’s Medical-Surgical Nursing ANZ 5th ed. Elsevier. Australia
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3.
Number the techniques for tracheostomy suctioning in the correct order 1-7.
Correct order
Techniques for tracheostomy suctioning
Review facilities policies and procedures to see if you are able to perform
tracheostomy suctioning
Hand hygiene, don gloves/PPE then attach the catheter to the suction
tubing and set suction pressure to 80–120 mmHg
Check medical officer’s orders, explain procedure to the patient, gain
consent, gather equipment
Report immediately if there is any difficulty in inserting the catheter into the
tube
When suctioning is finished check to see if the patient requires hyper
oxygenation. Replace humidification devise back onto tracheostomy tube,
make sure inner tube is clean.
Reinsert the clean inner tube
Clear suction catheter and tubing with sterile water
If possible, sit the patient up, place a waterproof
pad across individual’s chest, and remove humidification (or ventilation)
device (i.e., Swedish nose)
Ask the individual to cough and breathe slowly and deeply and insert the
catheter without suction into the tracheostomy tube just past the correct
length of the tracheostomy tube.
Apply suction and withdraw the catheter, rotating it gently.
Suction for no longer than 5–10 seconds at a time.
Allow the individual to take 4–5 breaths between each aspiration.
If secretions are thick, dip the catheter into sterile water and apply suction
− Porritt, K. (2021). Nursing care of an individual: Cardiovascular and respiratory. In G, Koutoukidis,
& K, Stainton (Eds.), Tabbner’s Nursing Care (Australian Version, 8thed., pp. 713-788). Elsevier
− Section titled: Nursing a person with a tracheostomy
4.
Outline the rational for the following when commencing oral suctioning of a patient.
Rationale
Why is it important to perform hand hygiene.
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Why is it important to position the patient
(where possible) into a semi-fowlers
position prior to oral suctioning
− Ingham-Broomfield, B. (2021). Supporting oxygenation and perfusion. In J. Crisp, C. & Douglas,
G. Rebeiro, & D. Waters (Eds.), Potter & Perry’s fundamentals of nursing (Australian version, 6th
ed., pp. 738-824). Elsevier.
− Section titled: Oral suctioning
5.
Outline three (3) nursing cares you need to perform for a patient with an Intercostal catheter (ICC).
Porritt, K. (2021). Nursing care of an individual: Cardiovascular and respiratory. In G,
Koutoukidis, & K, Stainton (Eds.), Tabbner’s Nursing Care (Australian Version, 8thed., pp. 713788). Elsevier
Section titled: Nursing a person with a chest drain
6.
Outline two (2) specific nursing actions to ensure that the underwater sealed drain (UWSD) unit
works effectively.
Porritt, K. (2021). Nursing care of an individual: Cardiovascular and respiratory. In G,
Koutoukidis, & K, Stainton (Eds.), Tabbner’s Nursing Care (Australian Version, 8thed., pp. 713788). Elsevier
Section titled: Nursing a person with a chest drain
……………………………………………………………………………………………………………………………………….
7.
Outline three (3) nursing cares you need to perform for a patient with a colostomy and stoma.
Wakefield, H. (2021). Nursing care: Bowel elimination and continence. In G, Koutoukidis, & K,
Stainton (Eds.), Tabbner’s Nursing Care (Australian Version, 8thed., pp. 1023-1047). Elsevier
Section titled: Care of individual with a stoma
……………………………………………………………………………………………………………………………………….
A 16-year-old female fell from her horse and fractured her left femur, she has balanced
suspension skeletal traction in place.
8.
Identify four (4) nursing cares for a patient who is in traction.
Wollan, M. & McLiesh, P. (2020). Nursing Management: Musculoskeletal trauma and orthopaedic
surgery. In D, Brown. & H, Edwards. (2020) Lewis’s Medical-Surgical Nursing ANZ (5th ed., pp. 16811721). Elsevier
Section titled: Traction
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A 56-year-old male patient is day two post operative following insertion of a suprapubic catheter.
9.
Identify three (3) nursing actions you need to be aware of when caring for a suprapubic catheter.
Perry, A.G. Potter, P. Ostendorf, W. & Laplante, N. Urinary elimination. Clinical Nursing Skills and
Techniques, 34, 994-1026 (2022).
Section titled: SKILL 34.5 Suprapubic catheter care
10.
Outline six (6) nursing practices you are to follow when entering the room of a patient on isolation
precautions due to Norovirus, who requires vital signs to be attended to.
Munday, J. (2021). Preventing and controlling infection . In J. Crisp, C. & Douglas, G. Rebeiro, & D.
Waters (Eds.), Potter & Perry’s fundamentals of nursing (Australian version, 6th ed., pp. 416-476).
Elsevier.
Section titled: Protective environment
……………………………………………………………………………………………………………………………………….
11.
Identify two (2) ways to check if the nasogastric (NG) tube is in the correct position prior to
administering feeding solution.
Access your ClinicalKey and go to Clinical skill tab, select N then from the list select Nasogastric
or Orogastric Tube: Insertion, Flushing, and Removal – CE.
Watch the videos:



Inserting a nasogastric tube
Managing a nasogastric tube
Removing a feeding tube
……………………………………………………………………………………………………………………………………….
12.
Why is it important to flush the NG tube during continuous feeding?
Access your ClinicalKey and go to Clinical skill tab, select N then from the list select Nasogastric
or Orogastric Tube: Insertion, Flushing, and Removal – CE.
Watch the videos:



Inserting a nasogastric tube
Managing a nasogastric tube
Removing a feeding tube
……………………………………………………………………………………………………………………………………….
13.
What position should the patient be in for intermittent percutaneous (PEG) feeding?
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NG, PEG and enteral feeding, please read through the chapter Meeting nutritional
needs section titles:



Enteral access tubes
Administering enteral feeding via nasoenteric tube
Person-centred interdisciplinary nutrition care
from the textbook in ClinicalKey.
Marshall, A. and Roberts, S. (2021) Meeting nutritional needs . In J. Crisp, & A. Potter, Potter &
Perry’s Fundamentals of Nursing (ANZ version, 6th ed., pp. 912-963). Elsevier
……………………………………………………………………………………………………………………………………….
14.
Identify the two (2) ways prepared enteral feeding can be administered via a percutaneous
endoscopic gastrostomy [PEG) and jejunostomy (percutaneous endoscopic jejunostomy [PEJ)
devices.
Week 3 Lecture – Acute Gastrointestinal Disorders
……………………………………………………………………………………………………………………………………….
15.
Identify three (3) reasons a patient may require nutritional requirements via an enteral tube.
Rodier, D.(2021). Promotion of health and wellbeing: Nutrition. In G, Koutoukidis, & K, Stainton
(Eds.), Tabbner’s Nursing Care (Australian Version, 8thed., pp. 943-983). Elsevier
Section titled: Nasogastric tubes & Gastrostomy tubes
……………………………………………………………………………………………………………………………………….
Jack Hue’s wife states her husband snores too much and sometimes takes a while to take a
breath during his sleep. Jack admitted he has been feeling sleep deprived and fatigued. He
attended a sleep studies clinic and was diagnosed with sleep apnoea and is required to use a
continuous positive airway pressure (CPAP) machine.
16.
Outline three (3) reasons for the use of continuous positive airway pressure (CPAP) and bilevel
positive airway pressure (BiPAP) for sleep apnoea.
Redmond, H. (2021). Obstructive sleep apnoea Promotion of health and wellbeing: Rest and
sleep. In G, Koutoukidis, & K, Stainton (Eds.), Tabbner’s Nursing Care (Australian Version,
8thed., pp. 826-844). Elsevier
……………………………………………………………………………………………………………………………………….
17.
As an EN identify two (2) nursing cares you may be able to perform in regards to a PICC.
Harding, M. & Alexander, K. (2020). Nursing Management: Fluid, electrolyte and acid–base
imbalances. In D, Brown. & H, Edwards. (2020) Lewis’s Medical-Surgical Nursing ANZ (5th ed., pp.
313-345). Elsevier. Section titled: Nursing Management: Central Venous Access Devices
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……………………………………………………………………………………………………………………………………….
18.
What are defibrillators used for?
Bucher, L. & Buckley, T. (2020). Nursing Management: ECG monitoring and arrhythmias. In D,
Brown. & H, Edwards. (2020) Lewis’s Medical-Surgical Nursing ANZ (5th ed., pp. 871-893). Elsevier
Section titled: Defibrillation
……………………………………………………………………………………………………………………………………….
19.
What are artificial cardiac pacemakers used for?
Bucher, L. & Buckley, T. (2020). Nursing Management: ECG monitoring and arrhythmias. In D,
Brown. & H, Edwards. (2020) Lewis’s Medical-Surgical Nursing ANZ (5th ed., pp. 871-893). Elsevier
Section titled: Pacemakers
……………………………………………………………………………………………………………………………………….
20.
Answer the questions in the table relating to shock and tension pneumothorax.
Identify five (5) clinical
indications of shock
What is the acute
surgical intervention
for a tension
pneumothorax
− Carbino, G. (2020). Shock Emergencies. In A, Sweet. & A, Foli. (2020) Sheehy’s Emergency
Nursing (7th ed., pp. 205-215). Elsevier
− Section titled: Clinical Manifestations of Shock
− Section titled: Circulation and Perfusion in Obstructive Shock
21.
Answer the questions in the table relating to full-thickness burns.
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Identify two (2) clinical signs of a
full-thickness burns
Acute surgical Intervention
Full-thickness
burns
− Knighton, J. Aiken, R. & Rowe, S. (2020). Nursing Management: Burns. In D, Brown. & H,
Edwards. (2020) Lewis’s Medical-Surgical Nursing ANZ (5th ed., pp. 871-893). Elsevier.
− Section titled: Extent of Burn
− Section titled: Nursing and Interprofessional Management: Acute Phase – Excision and grafting
22.
Outline three (3) nursing actions to prevent dehydration in a patient who has just returned from
theatre following abdominal surgery and is Nil-by-mouth (NBM).
Foran, P. & Hoch, C. (2020). Nursing Management: Postoperative care. In D, Brown. & H,
Edwards. (2020) Lewis’s Medical-Surgical Nursing ANZ (5th ed., pp. 387-412). Elsevier
Section titled: Nursing implementation
……………………………………………………………………………………………………………………………………….
Melinda, a 24-year-old female with acute myeloid leukaemia. She had undergone a bone marrow
transplant, which had yet to take and is neutropenic. Care must be taken to ensure Melinda does
not become septic.
23.
Answer the questions in the table below in regards to what sepsis is and how you can identify
sepsis.
Sepsis
Pathophysiology
Early Clinical signs
and symptoms
Seckel, M. and Lin, F. (2020). Nursing Management: Shock, systemic inflammatory response
syndrome and multiple organ dysfunction syndrome. In D. Brown & H. Edwards, Lewis’s
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Medical Surgical Nursing (5th ed., pp. 1825-1849). Elsevier Health Sciences.
Nursing in the acute care environment section title Sepsis from the textbook in ClinicalKey.
Nursing Management: Shock, systemic inflammatory response syndrome and multiple organ
dysfunction syndrome section titled Interprofessional Care: Specific Measures from the
textbook in ClinicalKey.
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Ms Wander has angina and is admitted to the cardiac ward for a cardiac catheterisation
procedure.
24.
Discuss the reason a person may require cardiac catheterisation.
− Porritt, K. (2021). Nursing care of an individual: Cardiovascular and respiratory. In G, Koutoukidis,
& K, Stainton (Eds.), Tabbner’s Nursing Care (Australian Version, 8thed., pp. 1330-1352). Elsevier
− Section titled: Cardiac catheterisation
− Shaffer, R. Bucher, L. & Roiley, J. (2020). Nursing Management: Coronary artery disease and
acute coronary syndrome. In D, Brown. & H, Edwards. (2020) Lewis’s Medical-Surgical Nursing
ANZ (5th ed., pp. 387-412). Elsevier
− Section titled: Cardiac catheterisation
……………………………………………………………………………………………………………………………………….
End of Assessment
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