complex nursing care of clients SAMPLE

HLT07 Health Training Package

Learner resource

Version 2

Training and Education Support

Industry Skills Unit

Meadowbank

Product Code: 5565

HLTEN505B Contribute to the

complex nursing care of clients

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HLTEN505B Contribute to the complex nursing care of clients

© TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2012

Acknowledgments

The TAFE NSW Training and Education Support Industry Skills Unit, Meadowbank

would like to acknowledge the support and assistance of the following people in the

production of this learner resource guide:

Writers:

Rhonda Albani Kathryn Austin Dorothy Barnes Kylie Brennan

Sherryl Dismorr Elaine Foss Beth Rutherford Sue Spozetta

TAFE NSW

Reviewers/Editor:

Michelle McKay

Jacqueline Handley

Kylie Brennan

Liz Bougaardt

Amanda Culver

Wendy Howe

TAFE NSW

Project Manager:

Amanda Culver

Project Coordinator

Training and Education Support, Industry Skills Unit, Meadowbank

TAFE NSW

Acknowledgements are also given to all TAFE NSW facilitators of the Enrolled Nurse

Education Program.

Enquiries

Enquiries about this and other publications can be made to:

Training and Education Support Industry Skills Unit, Meadowbank

Meadowbank TAFE

Level 3, Building J,

See Street,

MEADOWBANK NSW 2114

Tel: 02-9942 3200 Fax: 02-9942 3257

ISBN 978-1-74236-302-8

© TAFE NSW (Training and Education Support, Industry Skills Unit

Meadowbank) 2012

Copyright of this material is reserved to TAFE NSW Training and Education

Support, Industry Skills Unit Meadowbank. Reproduction or transmittal in

whole or in part, other than subject to the provisions of the Copyright Act, is

prohibited without the written authority of TAFE NSW Training and Education

Support, Industry Skills Unit Meadowbank.

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© TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2012

Table of contents

Introduction ....................................................................................... 7

1. General introduction ............................................................................. 7

2. Using this learner guide ........................................................................ 8

3. Prior knowledge and experience ............................................................10

4. Unit of competency overview ................................................................10

5. Assessment ........................................................................................12

Section 1 Introduction and essential knowledge required to contribute to the complex nursing care of clients ......... 13

Section 2 Circulatory, blood and lymphatic systems ..................... 15

Section 3 Gastrointestinal system ................................................ 61

Section 4 Respiratory system ....................................................... 99

Section 5 Endocrine systems ...................................................... 129

Section 6 Urinary system ........................................................... 149

Section 7 Reproductive systems ................................................. 167

Section 8 The nervous system .................................................... 183

Section 9 Special senses ............................................................ 215

Section 10 Musculoskeletal system .............................................. 231

Section 11 Integumentary system ............................................... 259

Reference List................................................................................. 277

Resource Evaluation Form .............................................................. 279

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© TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2012 Page 13 of 282

Section 1 Introduction and essential

knowledge required to contribute to

the complex nursing care of clients

The following list outlines the essential knowledge required of an enrolled nurse to

contribute to the complex nursing care of clients.

Organisational policies and procedures including workplace health and safety

legislation

Review microbiology and infection control

Review activities of daily living

Ethical guidelines including confidentiality and duty of care

Referral options and resources available in community and health care setting

Review communication skills, interviewing, mediation, negotiation, conflict

resolution, non-judgemental attitude

Social Justice principles.

It is advised that you review the following units where the above essential knowledge

will be found to familiarise yourself with these topics before commencing this unit.

HLTEN502B Apply effective communication skills in nursing practice

HLTEN509B Apply Legal and ethical parameters to nursing practice

HLTIN301C Comply with infection control policies and procedures

Brief overview of essential knowledge

When undertaking any nursing care of a client it is imperative that you adhere to all

Organisational polices and procedures. In addition you must adhere to all legislation

relevant to you care including workplace health and safety. Infection control plays an

important part in your care for a client. This includes knowledge of both standard and

additional based precautions.

When delivering all nursing care it is vital that you adhere to all ethical guidelines.

You have a duty of care to your client and must maintain confidentiality. You also

need to be aware of social justice principles which mean that the rights of all people in the community are considered in a fair and equitable manner.

Communication involves the transference of verbal or non-verbal information

between people and hence people affect one another through the exchange of

information, ideas and feelings. Effective and empathic communication is necessary

for the provision of quality care and it is essential to the development of a therapeutic

relationship between the client and the nurse.

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Page 14 of 282 © TAFE NSW (Training & Education Support, Industry Skills Unit Meadowbank) 2012

Advocacy means the nurse acts for and on behalf of the client, to act as an advocate.

The nurse must ensure the client is provided with adequate and accurate information

relating to his/her care so they can make an informed decision.

For each condition covered ensure the following content is included:

Perform nursing interventions to assist the client with complex needs

Advocate for clients in health and/ or community settings

Contribute to the nursing care of clients with common disorders/ conditions.

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Section 2 Circulatory, blood and lymphatic

systems

2.1 System review/terminology/diagnostic tests

Review anatomy and physiology notes and text related to circulatory, blood and

lymphatic systems.

Activity 1

Using related text or the internet, revise your knowledge of the anatomy and

physiology of the blood and lymphatic system. Match the following words with the

statements below:

red bone marrow

leucocytes

six

carbon dioxide

erythrocytes

haemoglobin

fifty-five

oxygen

haemoglobin

pathogens

thrombocytes

plasma

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Activity 1 (continued)

The liquid part of blood is known as

Red blood cells are called

White blood cells are called

Elements that play a part in blood

clotting include platelets, or

Oxygen is transported by a substance

in red blood cells. This substance is

called

The appearance of pus at a body site

indicates that the leucocytes are

actively involved in destruction of

An important gas that is transported by

the blood from the lungs to all parts of

the body is

The gaseous waste product carried by

the blood to the lungs is

The iron-containing protein in red blood

cells is a compound called

The connective tissue present in bone

that is the site of formation of blood

cells is

The average blood volume for an adult

is approximately….. litres of blood.

Plasma constitutes …..% of total blood

volume

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Activity 2

Using related text or the internet, complete the following table of diagnostic tests

for cardiovascular investigations.

Option Definition Letter

A. Arteriogram Ambulatory electrocardiographic monitoring.

B. Cardiac catheterisation

X-ray of an artery made after injection of a radio-opaque dye. Invasive procedure which includes arterial puncture.

C. Electrocardiogram Insertion of catheter into the heart to assess the status of the heart.

D. Echocardiograph Thallium scans.

E. Doppler Studies Exercise tolerance test. ECG is recorded whilst exercising.

F. Exercise stress test Recording of the heart‘s electrical action.

G. Nuclear studies Ultrasound imaging used to assess the movement of blood within the blood vessels. Non invasive and often used at ward level.

H. Cardiac Doppler These markers are released into the blood in large quantities from necrotic heart muscle after a myocardial infarction. Measured to indicate cardiac damage and approximate extent of damage

I. Cardiac enzymes Doppler ultrasonography is used to evaluate the direction and pattern of blood flow within the heart

J. Holter monitoring Use of ultra high frequency sound waves directed through the chest wall. Cardiac structures return echoes which are traced and recorded.

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Activity 3

Using related text or the internet, complete the following table related to blood

test. From the list below, fill in the name of the test in the column next to the

appropriate explanation.

Erythrocyte sedimentation rate

Serum lipids

Red blood count

Bone marrow biopsy

Haematocrit

White blood cell (WBC) count

Total haemoglobin

Name of Test Explanation

Collection of bone marrow by aspiration or biopsy. Needle

inserted through the skin and tissue e.g. over the iliac

crest or sternum until it reaches bone. A sample of bone

marrow is withdrawn

ESR measures the time required for erythrocytes, in a

sample of whole blood, to settle to the bottom of a tube.

Measures the percentage of a given volume of blood

occupied by erythrocytes

Measurement of the number of erythrocytes in a microliter

of blood

Measures the grams of haemoglobin (Hb) in 100mL of

whole blood

Measures the number of white cells found in a microliter of

whole blood.

Measures total cholesterol, triglycerides, LDL and HDL (see

below) levels

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A. LDL cholesterol

Low density lipoprotein (bad cholesterol) is a plasma protein that transports

cholesterol and triglycerides from the liver and small intestine to cells and tissues.

It transports cholesterol to the arteries and can be retained there, thus starting

the formation of plaques. Increased levels are associated with atherosclerosis

which is responsible for MI, Stroke and PVD.

B. HDL cholesterol

High density lipoproteins (good cholesterol) can remove cholesterol from

atheroma within arteries and transport it back to the liver for excretion. Therefore

high HDL levels have a protective value against Stroke, MI and PVD.

Triglycerides

It is a fatty acid that is the main constituent of vegetable oil and animal fats. They

are used by the body for energy as free fatty acids and also make up a major

component of LDL. Therefore when in abundance in the bloodstream, they lead to

atherosclerosis.

Activity 4

Using related text or the internet, complete the following table of terminology

related to the cardiovascular system.

Read each definition and place the letter of the correct term in the box provided


A. Thrombosis Deposits of fats and minerals in the inner

walls of large and medium sized arteries

that narrows the lumens of the vessels. A

form of arteriosclerosis.

B. Embolism A thickening, loss of elasticity and

calcification of artery walls resulting in

decreased blood supply

C. Ischaemia High blood pressure

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Activity 4 (continued)


D. Necrosis Localised death of a portion of tissue as a

result of disease or injury.

E. Hypertension An irregularity in the rhythm of the heart

beat.

F. Oedema The formation of a clot in a blood vessel of

the body.

G. Intermittent

claudication

Obstruction of a blood vessel by a foreign

substance e.g. blood clot which has been

moved in the blood.

H. Infarction Cramp-like pains in calf muscle which occur

during walking but subside with rest.

Results from inadequate blood supply to

the leg muscles

I. Arrhythmia Abnormal accumulation of fluid in the

intercellular tissue spaces of the body.

J. Atherosclerosis Localised area of tissue death resulting

from tissue anoxia caused by interruption

to blood supply to that area.

K. Arteriosclerosis Decreased blood supply to an organ or part

of the body.

L. Thrombophlebitis Constriction or narrowing of an opening or

passageway

M. Phlebitis Inflammation of the vein in conjunction

with the formation of a thrombus.

N. Stenosis Inflammation of a vein without clot

formation.

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complex nursing care of clients SAMPLE