HLTENN004 Implement, Monitor and Evaluate Nursing Care Plans
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Attention Students:This is an editable word document.This word copy of assessment is for student to work offline. Please DO NOT upload this document in Student Hub. You can copy and paste answers from this word document to your online assessment. AssessmentsCourse Unit:HLTENN004 Implement, monitor and evaluate nursingcare plansAssessmenttype:Theory AssessmentDisplaying 1 to 16 out of 16 total. 1. Comfort, rest and sleep are important factors in an individual’s life. Answer the following questions. (50 words each answer)1.1Identify four (4) factors that promote comfort, rest and sleep. 1) Comfort comes when the person has stress-free life and during that time period, the person can also get good amount of sleep. 2) Environment factor help the person in getting suitable comfort (Pun
and et.al., 2005). 3) Relaxed mind brings comfort and at the same time it helps the person to get sleep for minimum number of hours. 4) Proper health is essential component of comfort and sleep. 1.2Identify four (4) factors that impede comfort, rest and sleep. 1) Hourly observations2) When a person is having stress, it leads to inability to sleep and as aresult it changes the state of mind. 3) Similarly, lack of time and improper scheduling also leads to discomfort which does not led the person sleep (Huber, 2013).4) Noise and other disturbing factors impedes sleep and 4 rest. 2. Answer the following questions related to Activities of daily living.2.1Define activities of daily living. (50 words)In daily life, it is essential for the person to engage in various activities and practices such as work, personal life and other extra circular activities. The activities present in the life shows how the life operates along with the necessary things. 2.2List five (5) basic activities of daily living. (40 words)1) Assisting with dressing
2) Assisting with personal hygiene ie: shaving and brushing teeth3) Assisting with showering / bathing4) Assisting with eating meals / drinking5) Managing work as per the time schedule 3. Using proper aids to assist a client with their ADLs makes the activity safe and simpler for the clients. In the table given below, some scenarios are given. Choose the aids that would help you with assisting the client in the scenario. Also briefly state at least one easy way to assistthe client to maintain safety, privacy and simplicity. (40 words each answer)Activities of daily living Aids usedWays of assisting3.1A client has right sided hemiplegia. Client needs to wear a shirt. This is the basic activity in which the client is experiencing several problems. Since, one side is paralyzed; therefore nurse must assist him in wearing t-shirt. Aids Used – arm protector / sling Ways of assisting – by physically assisting the client3.2A client has difficulty feeding himself due to chronic osteoarthritis in wrist and knuckles. Aids used – Assistance is required from the nurse in terms of changing the ways to move. Nursing intervention can also be adopted at the same time so that the medical conditions can be improved.
Variety of equipment can be arranged for the client. Ways of assisting – cutting up the food3.3Client has Parkinsons disease moderately affecting his mobility. Client needs to get up from his bed and stand Aids used – Proper attention should be given towards the use of equipment that aids in managing movement. Movable chair can also be used at the time of managing movement of the client. Ways of assisting – through helping the client in moving from one place to another (Ouslander, Bonner, Herndon and Shutes, 2014). 3.4Client is old and had a recent fall. He finds it hard to walk by himself. In this case, nurse should adopt any sort of fall prevention strategy so that the client can be protected from further falls. Assistance is required to be given to the patient so that easy movement can be facilitated. Thus, wheel chair can be provided to the patient. 4. A 67 year old lady with history of stroke and left sided hemiplegiais admitted in your unit. She also has a history of type 2 Diabetes mellitus and acute renal failure (now resolved). She is having a second degree pressure sore in the sacral area. She is incontinent with urine and continent with faeces. She has upper dentures and lower row of own teeth. She uses bilateral hearing aids and glasses. She is on regular pain relief tablets and still has occasional pain in her left leg and gets headaches very often which is usually relieved by Paracetamol.Current reason for admission is lethargy and acopia at home. Family found the client confused at times and not attending to hygiene and grooming by self as she used to do before. You are assigned to provide
comprehensive care to her. Answer the following questions.4.1Mention four (4) purposes of hygiene and grooming. 1) To reduce infection2) To promote wellbeing3) To remain clean and tidy4) To get engaged in physical fitness 4.2Enlist four (4) contributing factors of pressure injury. 1) Pressure injury is caused in the lady because there is a pressure against the skin that limits blood flow to the skin and surrounded tissue. 2) Limited mobility is yet another reason that lead to pressure sore andthat can also make the skin vulnerable to damage (Model, 2015).3) Friction is regarded as the resistance to motion that may occur at the time when the skin is rubbed across a specific surface. 4) Pressure ulcer may also occur when the skin and underlying tissues are trapped among bone and surface.
5. With reference to the previous question, what are the actual/potentialnursing care needs of your client? (in 40 words each).Care needs Referrals/ care needs/ Nursing care5.1Mobility and transfers Referrals – Physiotherapy and Occupational Therapy due to history ofstroke and hemiplegia.Care Needs- the nurse need to ensure that proper equipment are being used to ensure movement of patients. 5.2Elimination needs Referrals - A urinal device for female can be used for the purpose of defecation.Care Needs – Continence aids. In this case, patient can use a bedpan or urinal if the patient has bed-bound or chair- bound. Similarly, nursecan also use a bedside commode through which the patient is able to walk for short distance. Nursing Care – would require toileting on a regular basis5.3Comfort and sleep (environment) Referrals – Focus should be laid on creating proper environment so that patient can find comfort (Carpenito-Moyet, 2006). Care needs – In order to give proper comfort and sleep, the nurse mustensure that the patient has taken all the medicines on time.
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