collecting a Basic Patient History

Task 3: Short Answer Questions. 40%

(Maximum word Count 750 words).

Question 1. You are collecting a Basic Patient History; formulate one closed ended question you would ask when interviewing the patient. (1 mark)

Do you take medications as per the prescription and the advice of the doctor?

Question 2. You are collecting a Basic Patient History; formulate one open-ended question you would ask when interviewing the patient. (1 mark)

How are you feeling now after you have stopped taking the two medicines which have caused a reaction in your body?

Question 3. Harking back to your Week 3 tutorial when introducing yourself to a patient for the first time it is key to establish a rapport to institute a strong and effective therapeutic relationship. Describe what key attributes you need to express when meeting a patient for the first time. (2 marks)

When meeting the patient for the first time, I will try to maintain eye contact with the patient. Further, I will also show empathy as well as communicate with the patient in a simple way. This will help the patient to share his/her problems and open up to me. On the other hand, I must also try to listen to the patient cautiously and assure that I will keep his/her word.

Question 4. You are on clinical placement and you are going to measure a patient’s blood pressure. How will you know if they were giving you implied consent to begin the procedure? (1 mark)

When the patient extends his/her arm, it implies that the patient has given his/her consent to check the blood pressure.

Question 5. Why, when on clinical placement, is it important to identify yourself as a Registered Nursing Student to the clients you are caring for? (2 marks)

It is important to identify myself as a registered nursing student to the client that I am caring for because sometimes the patients are not willing to perform the task that is the nurses ask them to do. It is the responsibility of the patient to adhere to the scope of practice and the actions that are provided to them by the nurse. In some cases, it is found that the patients do not want to take medicines or injections on the supervision of the nurse and thus in such circumstances, it is the responsibility of the nurse to express herself as a registered nurse towards the patient.

Question 6. List the key factors that influence the body’s ability to adjust fluid and electrolytes.(3 marks)

The key factors that influence the ability of the body to adjust the fluid and maintain electrolytes are environment, exercise as well as the overall health of the patient.

You are on clinical placement in a Medical Ward at a tertiary hospital You are looking after Harold Skimpole, a 69-year-old man who was admitted with weight loss. He has told the nurse that he has lost interest in many of his normal activities since his wife died. You decide to read the patient notes to learn more about Harold’s admission to hospital. Below are the nursing notes written by the previous nurse looking after Harold.

Question 7. Identify which “Guidelines for Recording” were not followed by this nurse.

(3 marks).

The factual aspects of the records have not been mentioned by the nurse. Further, the accurate intake of medicines and food by the patient has also not been discussed by the nurse. The record is not complete as well as it lacks an organised way. The confidentiality aspect of the patient has not been maintained in writing the report.

Note Questions 8 to 12 are connected to this case study.

HCCC (Health Care Complaints Commission NSW) versus Nurse Z

Case Heard at the NSW Nursing and Midwifery Tribunal 24^th April 2017.

Nurse Z had graduated as a Registered Nurse in 2010.

Nurse Z’s work history shows that he started a new position as a Registered Nurse in a perioperative and critical care ward on 12 January 2015 with three days of orientation to the unit.

From 18 February 2015, the Nurse Unit Manager (NUM) and Clinical Nurse Educator (CNE) on the ward began to respond to concerns raised by staff members regarding Nurse Z’s “nursing competence.”

Management’s concerns were directly discussed with Nurse Z and rosters were altered to ensure senior nursing staff were rostered to work with him for every shift he worked.

A record of “incidents and performance development strategies” for Nurse Z while employed on the ward shows that in March 2015, the NUM and CNE advised Nurse Z that they “expected more nursing competence from a Registered Nurse.” Nurse Z responded by requesting more in-service training. Although Nurse Z attended 15 in-service sessions specifically designed to address his practice deficits, problems continued to occur with greater frequency over the year to January 2016.

Over a twelve-month period, documented practice concerns collated by the NUM and CNE included

1. The respondent did not undertake a patient load independently during the time.

2. He attended 15 in-service training sessions.

3. He was attributed with four medication errors and eleven “near misses” (defined as an error but averted only by interventions by registered nursing staff).

4. He had made eight documentation errors.

5. He was associated with 16 clinical knowledge issues and 21 clinical care issues, 22 clinical communication issues as well as an ongoing lack of incorporating correct hand hygiene practices (Case continues next page)