Nursing Care Plan for Mr Nigel Wheeler

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
INTERNAL Holmesglen: HSYCS U:\HSB\Programs - Courses\NURSING\Course Delivery & assessment\2018\stage 1\HLTENN004 - Implement, monitor and evaluate nursing care plans\Assessments\
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 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.
INTERNAL Holmesglen: HSYCS U:\HSB\Programs - Courses\NURSING\Course Delivery & assessment\2018\stage 1\HLTENN004 - Implement, monitor and evaluate nursing care plans\Assessments\
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 range of motion
Improved respiratory
function
1. Assist with active ambulation
 Moving his legs wearing
some leg braces.
 Moving the toes separately
 Walking with nurses’
intervention and with stick.
 Massaging on the joints with
repeated motion
 Warming up with hot bags
around the painful joints to
get the blood pumping.
 Doing some breathing
exercise under the
physicians’ supervision sitting
in the semi Fowler’s position
to increase the tidal volume
in the lungs that helps in
taking breath.
 Use of inhaler and pumping
machines prescribed by
doctor.
 Arranging oxygen supply
whenever required.
Following 1 day of
nursing intervention the
goals were met as
evidenced by
Patient being able to
move within limited
range of motion
Moving legs and toes
assists in walking under
nurses’ supervision.
Breathing exercise and
use of inhaler process
supports in gaining relief
from shortness of breath.
INTERNAL Holmesglen: HSYCS U:\HSB\Programs - Courses\NURSING\Course Delivery & assessment\2018\stage 1\HLTENN004 - Implement, monitor and evaluate nursing care plans\Assessments\HLTENN004 2018.docx