Health Assessment & Nursing Care Plan Workbook for NURBN2000

School of Nursing, Midwifery and
Healthcare
Faculty of Health
Bachelor of Nursing
NURBN2000
Transition to Nursing Studies
Semester 1, 2018
Assessment 2 Part B
Health Assessment & Nursing
Care Plan Workbook

Student Name:
Student Number:
CRICOS Provider Number 00103D
Introduction
In Assessment Task 2 –Part B you are required to complete a comprehensive health
assessment and nursing care plan on information given to you in the case study- Mr. Kevin
Jones. The case study information is located in the Book – Case Study Guidelines for
Assessment Task 2 (B).
Using the information gathered from the case study of Mr. Kevin Jones, you are expected to
document the assessment you have undertaken. You are also asked to identify four (4)
priority issues, develop, implement and evaluate your nursing care plan for Mr. Kevin Jones.
All information is to be recorded in this Health Assessment & Nursing Care Plan Workbook.
Your completed Health Assessment & Nursing Care Plan Workbook will be assessed using
the marking guide in the NURBN2000 Moodle shell. Print a copy of the marking guide and
keep it with you while writing your Care Plan to ensure you answer the questions correctly.
Guidelines for Health Assessment and Nursing Care plan (Total: 2000 words)
 This assessment relies on students being familiar with the nursing process as you
will be required to follow the steps outlined in this process. If you are not familiar with
this, review in any recommended nursing textbook – however, this has been covered
in your prior EN training.
 Complete the workbook, ensuring you have answered all the questions
 Students will demonstrate clinical decision making skills in:
1. The Nursing Process.
2. Identification/ assessment of nursing problems (nursing diagnosis)
3. Planning and Implementation of nursing care
4. Documentation of nursing data.
5. Evaluation of nursing care
Read this plan for the assessment task:
Activity-Assessment Task 2: Total 2000 words

600 word assessment
Nursing Care Plan
3 Diagnosis/Problems
Expected outcomes
Interventions
Rationale
Evaluation
Referenced 600 word assessment identifying physical & mental health
components e.g. dehydration may result in anxiety & confusion (Gulanick
& Myers, 2012)
Remaining word count utilised in the rest of document (1400 words)
Your care planning will be based on your assessment data
Develop a Care Plan based on data gathered in your assessment (a,b,c).
Then, identify three (3) main nursing problems and provide goals,
interventions, rationale and implementation of that care.
Evaluate (how successful was the care for each of the 3 problems
identified)
Submit Workbook
Adult Health Assessment – Total: 2000 words
Outline:
1. Students are required to discuss the physical and mental health
components for the assessment (600 words). This will need to be written &
referenced according to academic writing & referencing standards.
2. Identify 4 major issues for Kevin Jones, his social history and provide a
summary of your overall assessment of him. Ensure that you use ‘objective’
language. This would be similar to what you would write in nursing notes as
an admission history.
3. Using the Nursing diagnosis section, select the three (3) health nursing
diagnosis that you think are a priority for Kevin and include the evidence from
your assessment that supports this.
4. Now prioritise these 3 important nursing problems to formulate a nursing
care plan for Kevin
5. Develop a nursing care plan with rationale (referenced) and related
interventions that could be implemented for Kevin.
6. Complete the evaluation sections of the care plan - identify ways that you
could measure success in relation to each of these interventions.
1. Write your 600 words referenced assessment below discussing the
physical and mental health components for Kevin. This will need to be written
according to academic writing & referencing standards.(NB: your assessment
will roll on the next page).

Mr Kevin Jones is a 75-year-old gentleman, admitted under my care with the
history of hypertension, and alcoholism. He had stroke and paralysis. Assessment is
necessary to identify the risk factors and appropriate intervention for improving the
physical and mental health outcomes (Berman et al., 2014).
Stroke in the patients may have caused Paralysis. It is the common disability.
Stroke and paralysis may cause impaired voluntary movement of muscles. It is due
to brain damage due to the permanent block of blood supply. Kevin leans on one
side. He has slurred speech as per assessment. He forgets where his right hand
may be. Slurred speech after a stroke may occur due to the damage to left
hemisphere of the brain called hemiplegic. Hemiplegia may have caused vision
problems and his swallowing and walking difficulties. It may become even severe if
neglected and walking difficulty increases the risk of fall (Ben Natan et al., 2016).
The patient seems to have impediments to mobility as a result of paralysis risk
assessment. Currently, the patient is using three-pronged stick, and he is anxious
about the balance. There may be a need to further assess the strength to perform
ROM. It will help determine if the patent can participate in the rehabilitative activities
and exercises. Further, assessment showed affect of paralysis on mental health
components. Lack of family members support may have caused anxiety and can be
due to independent nature of Kevin. He may not be able to perform his activities of
daily living. Fear of fall and injury in this situation can be due to anxiety. and is mainly
autonomic response (Berman et al., 2014). Kevin's agitated and irritated behaviour
with nurses and physiotherapist relates to severe anxiety. In this level of anxiety,
people are overwhelmed and report overloaded with stimuli. It needs immediate
treatment as Kevin has history of Depression and Anxiety (Kang et al., 2017).
The chest x-ray of Kevin revealed lower lobe pneumonia. It is the lower
respiratory tract infection (bacterial or viral). It is characterised by patchy
consolidation in the lower lobe. Fever, infection, or dehydration may have caused
disorientation in patient as per assessment. Dehydration and anxiety may have led
the patient to convey his needs poorly (Cacciatore et al., 2017). His case details
inform about fever, loss of appetite, taking fewer fluids, malaise and body ache over
the past few days. It may be the cause of loss of weight and dehydration. He is
complaining chronic cough with sputum. His vital signs are recorded as BP - 90/60,
Temp 38.3 (mild fever), O2 sats - 93%, Resp rate - 24/ min (indicating critical illness
and shortness of breath) (Berman et al., 2014). There are Crackles & wheezes on
auscultation, diminished breath sounds. Patient has low blood pressure that may
have increased the risk of another stroke. His auscultation reports indicate the
probability of pleural effusion. Thickening of the reactive airway wall and decreased
airway lumen may have caused Wheezes. Without treatment, it may lead to heart
failure (Manabe et al., 2015).
The loss of appetite and less fluid intake may have decreased urinary output.
Dehydration in Kevin has caused skin turgor dry, and mucous membranes dry.
Dehydration may have caused anxiety and confusion (Berman et al., 2014). The
excess protein intake by Kevin may have caused increased urine concentration. The
condition indicates excessive protein breakdown. Increased blood urea nitrogen is