HLTENN004: Assessment on Implementing, Monitoring Nursing Care Plans

This document presents a comprehensive nursing care plan assessment for the HLTENN004 course, focusing on implementing, monitoring, and evaluating nursing care plans. The assessment covers a wide range of topics, including factors influencing comfort, rest, and sleep, and the importance of activities of daily living (ADLs). It explores the use of aids to assist clients with ADLs, addressing scenarios like hemiplegia, osteoarthritis, Parkinson's disease, and recent falls. The assessment includes a detailed case study of a 67-year-old patient with a history of stroke, diabetes, and other conditions, examining hygiene, grooming, pressure injury prevention, and falls prevention. The document further addresses nursing care needs related to mobility, elimination, nutrition, and personal hygiene. It also covers urinary incontinence, including treatment strategies and aids for toileting, and concludes with the initial steps of resuscitation. The assessment provides practical insights into various aspects of nursing care and patient management.

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Assessments
Course
Unit : HLTENN004 Implement, monitor and evaluate nursing
care plans
Assessment
type : Theory Assessment
Displaying 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)
1.1 Identify 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.
1.2 Identify four (4) factors that impede comfort, rest and sleep.
1) Hourly observations
2) When a person is having stress, it leads to inability to sleep and as a
result 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.
2.1 Define 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.
2.2 List five (5) basic activities of daily living. (40 words)
1) Assisting with dressing
2) Assisting with personal hygiene ie: shaving and brushing teeth
3) Assisting with showering / bathing
4) Assisting with eating meals / drinking
5) 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 assist
the client to maintain safety, privacy and simplicity. (40 words each
answer)
Activities of daily living Aids used Ways of assisting
3.1 A 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 client
3.2 A 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 food
3.3 Client 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).
3.4 Client 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 hemiplegia is
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.
4.1 Mention four (4) purposes of hygiene and grooming.
1) To reduce infection
2) To promote wellbeing
3) To remain clean and tidy
4) To get engaged in physical fitness
4.2 Enlist 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 and

that 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/potential
nursing care needs of your client? (in 40 words each).
Care needs Referrals/ care needs/ Nursing care
5.1 Mobility and transfers
Referrals – Physiotherapy and Occupational Therapy due to history of
stroke and hemiplegia.
Care Needs- the nurse need to ensure that proper equipment are being
used to ensure movement of patients.
5.2 Elimination 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, nurse

can also use a bedside commode through which the patient is able to
walk for short distance.
Nursing Care – would require toileting on a regular basis
5.3 Comfort 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 must
ensure that the patient has taken all the medicines on time.
Nursing Care – Relaxation technique can be used so that the patient
can sleep.
5.4 Nutrition needs
Referrals – Speech therapist to assess ability to swallow; Dietician to
ensure caloric intake is appropriate and diabetes is managed.
Care needs- There must be proper follow up on diet chart so that
appropriate diet can be taken.
Nursing care – Nurses are required to emphasize on monitoring and
controlling so that to ascertain if proper dietary is being adopted.
5.5 Oral hygiene
Referrals – Focus should be laid on dentistry so that proper care can
be conducted for the teeth. In this respect, patient should be
recommended to use fluoride toothpaste.
Care needs- interdental cleaning services are required to be given so

that fungal infection may not catch up (Bhui, Warfa, Edonya,
McKenzie and Bhugra, 2007).
Nursing care – Nurses must check if the tooth surface are properly
cleaned as that aids in staving off the cavities.
5.6 Personal hygiene and grooming
Referrals – In order to manage personal hygiene, it is essential for the
patient to follow proper schedule for bathing and cleaning.
Care needs- There must be proper training and counselling sessions so
that patient can learn more and can grab knowledge on different
aspects.
Nursing care – Nurses must also focus on proper monitoring and
controlling on activities of patient regarding the daily schedule.
5.7 Falls prevention
Referrals – Physical exercise can be adopted by the patient as a long
way to prevent falls.
Care needs- At the time of movement, it is essential for the patient to
wear sensible shoes so that it can prevent stumble and fall.
Nursing care – Nurses must adopt evidence- based falls prevention
programs so that several activities can be adopted which can reduce
the risk of falls (Grol, Wensing, Eccles and Davis, 2013). This can
also done through improving balance, flexibility and muscle strength.

5.8 Pressure injury prevention
Referrals – Nurse should consider the use of bedfast and chairfast for
the purpose of avoiding risks of development of pressure injury.
Along with this, a structured risk assessment can also be adopted.
Care needs- Nurse must assess pressure points such as the sacrum,
coccyx, heels and trochanetrs.
Nursing care – Nurses can use assistive devices such as slide sheets,
transfer boards or hoists. Changes can also be made to the movement
of the bed so that it can help in minimizing friction and shear.
5.9 Prevention of deconditioning
Promote active exercise as tolerated by the client
Promote deep breathing exercise if spending a fair amount of time in
bed (Pun and et.al., 2005)
Physical training can also be provided to the patient so as to avoid the
issues of hypertension and cardiac diabetes.
Patient should avoid sedentary lifestyle because that may affect the
heath values.
6. Urinary incontinence is one of the most chronic health problems and
can be intractable and ongoing.
Specify two (2) examples each for the following treatment strategies of
urinary incontinence. (40 words each answer)

Treatment strategy Examples(2)
6.1 Behavioural technique
1) Pelvic floor exercises
2) Biofeedback
6.2 Pharmacologic technique
1) Oestrogen
2) Collagen
6.3 Mechanical treatment
1) Pessaries
2) Urethral insert (in/out catheter)
7. Urinary incontinence is one of the most chronic health problems and

can be intractable and ongoing. (50 words each answer)
7.1 68 year old Janice complains of urge incontinence. Janice is a slow
walker and uses a 4 wheeled walker for ambulation. Janice had a fall
while trying to get to the toilet to urinate. What aids could be used to
assist Janice with toileting? How can we make Janices environment
safe to avoid falls?
- Place commode beside the bed (Bryant‐Lukosius, DiCenso, Browne
and Pinelli, 2004)
- referral to Incontinence advisor
Further, she could also be provided urinal devices so that her health
conditions can be resolved as early as possible.
Nurse can also be appointed at the same time so that she can assist her
in managing toiletry.
7.2 82 year old Bob is under palliative care. Bob is bed bound. Bob has
functional incontinence of urine and faeces. This makes him highly
susceptible to pressure injuries, macerations and skin breakdown.
Also, it would be very uncomfortable for client. What aids could be
used to assist Bob with toileting comfortably?
- Use of urodome and continence pads
- Regular turning
- The nearby area should be kept dry all the time so nurses are
required to ensure that proper hygienic aspects can be
undertaken.

8. You find a 63 year old female on the floor of the living room who is
not arousable. Describe the initial steps of resuscitation (in 40 words
each answer).
Steps of resuscitation Description
8.1 Dangers – Assess danger around the situation and ensure it is safe to
approach patient.
Proper methods should be included so that the patient can manage
movement from one place to another.
8.2 Responsiveness -
In order to get response from the patient, it is essential for the nurse to
ensure that proper appearance is being managed (Goldberg and et.al.,
2004).
8.3 Send – for help
Nurses should also get ready to help the patient so that she can get
recovered as early as possible.
8.4 Airway
8.5 Breathing

physical exercises can be carried out so that the physical fitness of the
patient can be enhanced. Breathing can be managed through focusing
proper ventilation.
8.6 Defibrillation
Use of Automatic external defibrillator
9. Mrs. Alice, a known case of asthma has recently been admitted into
the unit where you work. Recently she fell at home and sustained a
hipbone fracture. She is having severe pain in the hip and groin area
which makes it difficult to walk. From your observation she seems
severely malnourished. Answer the following question based on the
scenario
9.1 Identify ten (10) actual and potential nursing interventions that can be
provided to Ms. Alice to reduce pain (in 100 words)
In order to reduce pain level, muscle relaxation techniques can be
used.
There must be proper control on environmental factors such as noise

in patient’s room.
Reposition facility should be given to the patient in every 2 hours
because it might aid in preventing from pressure ulcers.
There must be direct education to the patient regarding relaxation of
the muscle to reduce the level of pain.
The patient should also get pain medicine q4 according to physician’s
prescription.
Nurse must also aware the patient about pleasurable sensory stimuli to
reduce the perception of pain.
Nurse should also secure a bed board under the mattress especially on
orthopedic bed (Boswell, Kraus, Miller and Lambert, 2015).
Support should also be provided to fracture site with pillows and
folded blankets. Hence, neutral position should be maintained for the
affects part with sandbags and splints.
Nurse must observe and evaluate splinted extremity to resolve edema.
Sufficient personnel should be used to turn the patient.
9.2 Describe the nursing care to manage the respiratory problems related
to chronic asthma.(50 words)
Patient need to undergo with tests so as to identify the substances that
precipitate the symptoms. Allergens can be utilized to prevent
communicable problems.
Evaluation of impairment is essential in identifying and controlling

risks.
9.3 Describe four (4) nursing interventions to improve the nutritional
status of Alice (in 150 words)
Proper diet chart is required to be followed so that the patient can get
suitable amount of nutrition at the same time (Moorhead, Johnson,
Maas and Swanson, 2014). This should include healthy ingredients so
that asthma related issues could be resolved.
Moreover, in this respect, nurses should also set several parameters of
nursing nutritional care so that health aspects of the patient can be
resolved.
In the similar way, the choice of patient should be directed towards
nutritional food. Sedentary lifestyle should be discouraged.
Further, a functional supportive and educational nursing should also
be supported similarly.
10. With reference to the previous question, mention four (4) nursing
interventions each to prevent the following complications of immobility(
in 30 words each answer)
Complications Nursing interventions(4)
10.1 Pressure injury
In order to reduce the complications of pressure injury, the patient
should be properly moved from one place to another.

10.2 Constipation
Proper schedule should be made so that lot of drinking water can be
used. At the same time, it can also be said that focus should be laid
on conducting physical exercises. Constipation can be managed
through changing the digestion system.
10.3 Contractures
Proper supportive actions can also be taken in the area of managing
bone and other systems (Huber, 2013). Physical support can be given
to the patient respectively.
10.4 Chest infection
In order to prevent chest infection, proper consultation is required
with the dermatologists so that further issues for skin diseases can be
managed.
11. Mr. William, 85 years old male client is living in a long-term care
facility. He is having progressive dementia over the past seven years and
is unable to care for himself independently due to cognitive decline. He
has got visual and hearing impairment.

Identify actual and potential nursing interventions to improve the self-
care ability of Mr. William in relation to the following (in 60 words each
answer)
11.1 Cognitive decline
Since, Mr William has cognitive decline; therefore it is essential for
the nurse to ensure that memory tools can be adopted so that patients
can try to remember things. Thinking ability can also be improved
through making notes and pictures for the patient and that should be
placed nearby the bed. Alongside, charts and timetables can also be
prepared accordingly.
11.2 Sensory deficits
Mr. Williams is required to get neurological physiotherapy treatment
so that to assess and treat sensory loss (Doenges, Moorhouse and
Murr, 2016). Physiotherapy treatment will also assist in improving
the mobility and balance. At the same time, it can also improve
communication and sense of wellbeing in the patient. The patient
could be provided soft tissue massage.

12. Good clinical handover and case meetings are vital to protect
patient safety. Briefly describe the recording and reporting
requirements for comprehensive clinical handovers and case meetings
(50 words).
Information related to the patients should be properly recorded and handed
to the patients in terms of maintaining confidentiality. This is also essential
for the purpose of developing secrecy aspects. Moreover, suitable clinical
handover is also essential because patients possess the right to be informed.
Apart from this, case meetings can also be conducted with the patients.
13. Mr Roy was admitted under your care with community acquired
pneumonia. As part of the treatment regime IV Benzyl penicillin
infusion was commenced. Minutes after commencement, client
complained of shortness of breath and itching all around the IV
cannula. On examination, you find that the client has wheeze, is short of
breath and has raised red rashes developing on the arm, face and neck.
SBP is low, patient is tachycardic, respiratory rate is 32, oxygen
saturation is 85% on room air.
13.1 What is possibly wrong with Mr Roy? Rationalise your answer. (80
words)

Mr Roy has community acquired pneumonia and he is also suffering
from cardiovascular disease; thus this went wrong with him. Both the
problems occurred at the same time (Ackley, Ladwig and Makic,
2016). Further, the given medicine (regime IV Benzyl penicillin
infusion) did not work well in the situation because of the abnormal
oxygen saturation. The given medicine is not right because it is used
for Syphilis which is caused by Treponema pallidum. This has
caused shortness of breath and as a result, red rashes also appeared
on the body.
13.2 Describe how you would respond in this situation as an enrolled
nurse (50 words).
As an enrolled nurse, I would ensure to give adequate antimicrobial
therapy. This can be given for S pneumonia and atypical bacterial
pathogens. Thus, in this respect I would also undertake clinical
pathways which is an important tool to improve care. At the same
time, it can maximize cost effectiveness especially for hospitalized
patients.
14. You are posted in a post-operative unit to take care of the clients
after surgery. Answer the following questions
14.1 Describe how to perform deep breathing and coughing exercise of a
patient after surgery (50 words)
It is essential for let the patient breathe in deep and slow manner
through the nose (Rothrock, 2014). This can be done by expanding
the lower rib cage and also through letting the abdomen move

forward. The patient should be asked to breathe out slowly and
completely through pursed lips.
14.2 Enlist four (4) measures for maintaining a safe environment for the
patients (30 words)
There must be proper availability of all health care and safety
services.
Emphasis should be laid on cleanliness and hygienic aspects.
There must be proper implementation of consistent national
standards.
15. Episodic care is health care provided to a client during an episode of
illness. The main focus of this model of care is to treat the immediate
issues of the client. This model of care is proven to have lot of risk
factors as it lacks continuity of care and does not consider holistic care.
Give below are a list of situations where episodic care is commonly
sought. Write at least 2 related risk factors for each situation. (40 words
each answer)
15.1 86 year old client admitted from a nursing home with UTI and
delirium.
It is important for the physicians to keep in mind the potential risks
of overused of antibiotics in elderly patient. The patient also has the
risk of clostridium difficile infection (Nelson and Staggers, 2017).
This practice is not common; hence according to the prescribed

medication, antibiotics can be used. Age, dementia, hip fracture and
severity of illness are the major risk factors that can occur in the
present case.
15.2 6 month old baby is admitted with diarrhea and vomiting
It is apparent that diarrhea reduces the amount of water and minerals
from the body which is also called as electrolytes. This can also lead
to dehydration as babies can get dehydrated quickly. Increased
vomiting can also create problems in digestion; hence it requires
several medical assistance.
15.3 A client with delirium is posted for abdominal surgery.
Preventing delirium is highly effective in elective surgery since
preventive actions could be initiated timely. Aortic Abdominal and
Colorectal surgery can be termed as one of the chief interventions
that can be avoided to evaluate the predictors of delirium.
15.4 Client was admitted with pathological fracture in the lower legs and
is bed bound (Cunningham, Leveno, Bloom, Spong and Dashe,
2014). Recovery time is expected to be more than 2 weeks
Improper movements can create risks and it can also bring more
changes in the pressure sores. It also includes the risk of other
blusters in the body which can also bring rashes on the skin.
15.5 A client with BMI of 38 is admitted for treatment of chronic back
and knee pain. Client needs assistance with mobility and transfers
due to pain.
The client seems to be highly obese and since knee and back pain is

enhancing. While mobilizing to the hospital, it is essential to ensure
that proper stretchers and equipment are being used. This can be
considered as physical assistance.
15.6 A client is admitted with Depression and weight loss for
investigation. Client has lack of appetite and is non complaint to
previous therapeutic interventions
Along with physical, mental care is also required to be given so that
the issues of depression can be solved (Ouslander, Bonner, Herndon
and Shutes, 2014). It is also possible that inappropriate care and
treatment can bring several other risks to the client. Disinterest of
client in any sort of therapeutic intervention can also impact the
service delivery procedure.
16. Answer the following multiple choice questions on oral hygiene and
provide rationale for your choices.
16.1 While caring for dentures, which of the following statements are
WRONG? Select 3 (three) answers.
A small break or chip in the denture is ok. We have to report
only major damages

Dentures should be stored in labelled denture cup with cool
water if not being used
All surfaces of dentures should be brushed properly
Use of detergent on dentures are not advised
While cleaning, it is ideal to place the dentures in a sink half
filled with water and without a lining surface
Dentures must be soaked in commercial denture solution daily
16.2 Rationalise your choices in previous question. (50 words)
Denture care requires proper removal and rinsing of dentures after
eating. At the same time, it should be handled carefully. Moreover, it
is also required for the patient to clean the mouth after removing the
dentures. Dentures should also be soaked for overnight.
16.3 Which of the following statements are WRONG in relation to oral
care? Select 3 (three) answers.
Best way to moisturize oral mucosa is by using mouthwash

twice daily
Mouthwashes with alcohol available from pharmacy is good to
kill unwanted bacteria in mouth that causes halitosis
Regular flossing is recommended for health teeth and gums
Using lemon and glycerine for oral care is good for oral cavity
Mouthwashes should be free from alcohol, hydrogen peroxide
and sodium bicarbonate
16.4 Rationalise your choices in previous question. (50 words)
On the basis of above statement, it can be said that oral care is
important since it maintains healthy gums, teeth and tongue. Oral
problems include bad breath and cold sores; hence several prevention
can be taken accordingly (Model, 2015). These are treatable and
properly diagnosed.

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