HLTENN004 Implement Monitor and Evaluate Nursing Care Plans Assessment 2022

Assessment Instructions for Student
Section A – Program/Course details
Qualification Code HLT54115 Qualification Title Diploma of Nursing
Subject/Unit Code HLTENN004 Subject/Unit Title Implement monitor and
evaluate nursing care plans
Section B – Assessment task details
Assessment
number
1/5 Semester/Year: 1/2018
Assessment title: Nursing Care Plan 1
Assessment method ☐A – Direct observation/
simulation activities
X B – Written/Verbal Questioning
☐ C – Third party evidence
☐ D – Portfolio/Product
☐E – Project/Report
☐ F – Presentation
☐ G – Role plays
☐ H – Other
Assessment Task
Results
This assessment task will be marked as:
X Ungraded result: Satisfactory or Not Satisfactory
☐ Other (e.g. points): .
Assessment
Task
Nursing Care Plan
Section C – Assessment Requirements
Task instructions:
 Write your answer legibly in the spaces provided
 You must successfully complete the answers to be deemed satisfactory in this assessment.
 In the event of failure of an assessment, the student’s progress will be reviewed and eligibility for
a resit will be determined by the Course Co-ordinator/Program Manager as per departmental
policy listed in the student handbook. Where relevant, remediation may be offered prior to a
resit. A student who successfully passes a resit shall be awarded a PX.
Section D – Assessment Criteria
Performance Criteria
2.2. Identify contributing factors and implement appropriate strategies to prevent and manage skin
breakdown.
Knowledge evidence
Maintaining skin integrity and pressure area care
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Nursing Care Plan 1 – Assessment
_________________________________________________________________
Read carefully through the information below about Mr Nigel Wheeler, a new patient
on your ward. Study the nursing care plan which has been created for Mr Wheeler –
there are some important points missing in this plan. You must fill in the blanks (bullet
points&/or numbers) to ensure complete quality care for this patient.
Mr Nigel Wheeler
Biography:
Nigel is 86 years of age. Nigel lives in his own home with his wife. Nigel has just
been admitted to hospital ashe has had a series of falls over the past few weeks and
his Dr wants to investigate why this is happening so frequently in recent months.
Nigel is getting increasingly difficult to manage at home as his wife, who is 84 years
old, is quite frail and displaying early signs of dementia.
Medical Diagnosis:
Osteoarthritis, falls for investigation, pressure injury, constipation and depression
Care Related Needs:
His mobility is affected by the pain associated with his OA. Nigel is only able to
ambulate with assistance, which impacts his ability to perform ADL’s. Nigel finds it
difficult to get around and becomes exhausted and short of breath.
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HLTENN004 – Nursing Care Plan (using clinical reasoning)
Identify
problem/issue
Establish Goals
(With timeframes)
Take Action Evaluate Outcomes
(Has it worked)
Reflect on process
1. Impaired
physical
mobility related
to chronic pain
and evidenced
by:
 Limited range of
motion
 Slow movement
 Reluctance to
attempt
movement
2. Exertional
discomfort as
evidenced by
dyspnoea, client
complaining of
shortness of
breath, needing
assistance with
activities of daily
living, need for
frequent breaks
during activity
Increased movement
within the range of motion
Improved respiratory
function
1. Assist with active ambulation
 Advice and teach him about
active and passive exercise
and encourage to do it daily
 Encourage him to do his
work independently and
safely
 Encourage deep breathing
exercise.
 Advice the patient relatives to
not to leave him alone and
ensure the presence of one
assistance with the patient
 Encourage him to do simple
and easy tasks
 Provide positive
reinforcement when he is
attempting an activity
 Position the patient
comfortably and extra pillows
and cushions.
 Change his position every 2
hours. Concentrate on
pressure areas
 Put the side rails up and
reduce the height of the bed
and keep all necessary items
nearby.
 Advice him to call for help
whenever needed and teach
Following 1 day of
nursing intervention, the
goals were met as
evidenced by
Patient being able to
move within a limited
range of motion
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him to use the call bell
 Teach the patient’s family to
ensure the family
atmosphere and safe
environment
 Position in fowlers position
 Administer oxygen therapy if
prescribed by the doctor
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3. Self-care
deficits
ADL’s
Bathing
Grooming
Toileting
Dressing
due to restricted
movement
Foster self-care abilities
The patient can safely
wash his face, arms,
trunk and perineal area
with minimal help
1. Allow as much time as possible to
improve independence within safe
limits
2.Assist the patient to perform daily
bathing while promoting
independence in bathing the parts of
his body within his reach and ability
3.Recognize and respect the
personal choices of the patient in
food, grooming, and clothing
4.Provide positive reinforcement and
improve the self esteem
5. Advice the patient to understand
that he needs an assistant and
explain that it is for only a short
period.
6. Position the patient comfortably
while feeding.
7. Provide privacy whenever he
prefers and during dressing
8. Assist the patient in toileting,
encourage him to call for assistance
whenever he wants to void
9. Give suppositories if prescribed by
the doctor.
10. Teach the family members to
allow him independently to meet his
daily activities based on his ability.
Nigel showered himself
with minimal help.
Walked to and from the
bathroom on his own,
although quite nervous
and worried that he
might fall over.
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4.Pain (Right hip)
Progression of joint
deterioration causing
chronic pain to his
Right hip
Identify the current level of
pain intensity, and
determine comfort. &
function. Improvement of
pain and increase in daily
activities
1. Complete a pain assessment.
2. Barriers to client willingness to
report pain and use analgesics or
alternative therapies. Fears about
side effects and risk of addiction
3. Remove the stressful objects
cause pain from the environment
4. Administer analgesics as per
order and evaluate the effectiveness
of the medicine.
5. Apply hot compress. Ensure the
temperature of the water is not very
hot.
6. Encourage deep breathing
exercise which relaxes the muscles
and promotes comfort. Reassure the
patient.
7. Engage the patient in planning
pain management strategy.
Encourage the patient to verbally
express his feelings about pain and
plan the pain management strategy.
8. Help the patient in mobilization
and ensure limited mobility.
9. Educate the patient and his family
about pain management techniques
New medication
improving pain level.
Must maintain a low level
dose twice per day to
keep on top of the pain.
Nigel needs some
encouragement to take
it.
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like drugs, remedy and its side
effects.
10. Provide extra pillows and
cushions to reduce the pressure on
bony prominence and promote
comfort.
5.Fluid &
Nutritional Deficits
Nigel reports of inability
to have a bowel
movement and
associated discomfort
The client will maintain
passage of soft, formed
stool every 1-3 days
without straining
1. Assess the patient’s daily
nutritional and fluid intake.
2. Assess for signs and symptoms of
fluid imbalance and nutritional deficit.
3.Promote measures such as
 Regular time
 Routine daily time
 Provide stimulation eg
prune juice
 Allow adequate time
following meals
 Adequate exercise
4. Develop a fluid plan and meal
plan according to the preference of
the patient. Prioritize according to
the patient’s desire. Do not force any
food only because of its nutritional
benefits.
5. Administer oral nutritional
supplements as per doctors orders
6. Monitor and document the food
intake and its nutritional value to
check the progress of the patient
Unable to have a bowel
movement today
Managing additional
water today, but still
struggling to drink more
than 1 l
Medications reviewed
and client on several that
can cause constipation
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and Maintain intake output chart.
7. Encourage the patient to perform
mobilization which induces appetite
8. Monitor for signs and symptoms of
dehydration and educate the patient
and his family about the same.
9.Educate the patient and his family
about the importance of normal fluid
intake and nutritional intake
10. Administer IV fluids in case of
less fluid intake and severe
dehydration.
6. Impaired skin
integrity
Ulcer on sacrum
Progressive healing of
tissues and no new
injuries
1. Reduce irritating moisture
Monitor client’s continence
status
 Keep the potential
area clean and dry
 Use medical corn
starch to prevent
friction and irritation
 Use adult diapers to
prevent moisture
caused by
incontinence
2. Improve tissue perfusion
Avoid pressure/massage on
reddened areas
Pressure injury reducing
in size. Now the size of
20c piece edges
granulating and only a
small amount of serous
exudate.
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 Provide extra pillows
and cushions
 Provide back care
twice daily
 change the position
every 2 hours
Reduce head of bed <30̊ to
diminish pressure on his
bottom.
Use pressure relieving
devices such as
air/water/foam mattress
Reduce friction & shear
Do not position the client on
site of skin impairment.
Lift and do not drag patient
Ensure no wrinkles on bed
sheets
3. Improve nutritional status by
encouraging Nigel to eat a
well-balanced meal, high in
protein, Vitamin C, etc.
Weigh twice weekly
4. Promote wound healing:
 Assess the wound
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 Apply to dress
 administer analgesics
if needed
 Ensure hydration
 Encourage Nutritional
diet which includes
high protein and high
fibre diet.
 Prevent further falls
and ensure the
presence of one
assistant with the
patient.
7. Risk for falls
Impaired balance as
evidenced by client
walking unsteadily,
asking for assistance,
need to urinate urgently
and frequently, uses
the cane at home to
ambulate
The client will not
experience any falls during
stay
1. Orient client to the
environment. Assess ability
to use call bell, use of bed
rails, monkey bar, & bed
controls
2. Identify factors that may
cause or contribute to injury
from a fall. Complete FRAT
tool and eliminate any risks
identified, such as
assist the client in toileting
with their schedule
Keep the path to the
bathroom clear, leave the
door open.
3. Toilet prior to bedtime,
awakening, 2/24 while awake
Lower bed height
No falls since admission.
Hazards in the room
removed. Bathroom
door open at all times,
buzzer within reach
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8. Impaired
communication
Impaired
communication as
evidenced by client
repeatedly asking for
spoken communication
to be repeated
9. Impaired sleep
Impaired sleep as
evidenced by patient’s
fatigue and client
reporting lack of sleep
due to pain in R hip.
The client will be able to
understand the spoken
word.
The client will sleep well
during night time hours.
1. Assess the level of
communication. Assess the cause of
impaired communication. Plan the
strategies of improving
communication with the help of
therapists.
2. Use simple terms and appropriate
body language while communicating
with the patient. Remove
communication barriers from the
environment.
3. Allow the patient to express his
thoughts and do not hurry him to
respond within a time frame. Always
put forward the yes or no questions.
1. Mr. Wheeler understands the
spoken word and participates in
communication with others.
2. He is able to co-relate
communication and body language.
His level of understanding is improved
3.patient expressed his thoughts in
simple terms and hot hurried for a
reply
1. The patient slept comfortably and
has no complaints of sleep
deprivation.
2. Day time sleep was avoided by the
patient
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1. Position the patient comfortably
with extra pillows and cushion.
provide a blanket if he prefers
2. Advice the patient to avoid day
time sleep. Provide an activity during
the regular sleep time in the day.
Encourage mobility to improve sleep.
3. Ensure a calm and peaceful
environment. Ensure providing less
noise or Zero noise environment.
3. The calm and peaceful environment
is provided.
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