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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HLTENN004 2018.docx

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 2018.docx

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
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
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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