Nursing Care Plan: HLTENN004 - Implement, Monitor, Evaluate Care

This document is a completed nursing care plan for an 86-year-old patient, Mr. Nigel Wheeler, admitted to the hospital due to a series of falls and various health issues including osteoarthritis, a pressure injury, constipation, and depression. The care plan addresses multiple needs such as impaired mobility, exertional discomfort, self-care deficits, pain management, fluid and nutritional deficits, impaired skin integrity, risk for falls, impaired communication, and impaired sleep. The plan outlines goals, actions taken, and evaluation of outcomes for each identified problem, encompassing interventions like mobility assistance, breathing exercises, self-care support, pain assessment and medication, fluid and nutritional management, skin integrity maintenance, fall prevention strategies, and communication and sleep interventions. The document details the patient's biography, medical diagnosis, and care-related needs, providing a comprehensive approach to patient care and management.

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

 Fingertip rubbing on the rib
cage
3. Self-care
deficits
ADL’s
Bathing
Grooming
Toileting
Dressing
due to restricted
movement
Foster self-care abilities
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. Support patient in toileting
without anyone’s intervention
3. Collaborate by sitting in a
tilted back at an angle from
30 to 45 degree while
working with the
physiotherapist at the time of
doing breathe exercise.
4. Involving patient in taking
bath and washing face and
hands and other hidden body
parts whenever required by
his own or taking minimal
assistance from the nurses.
5. Grooming himself by cutting
own nail
Nigel showered himself
with minimal help.
Walked to and from
bathroom on his own,
although quite nervous
and worried that he
might fall over.
Doing necessary things
by own helps to gain
confidence and assists in
the self-care progress of
patients which leads to
fast recovery.
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

6. Dressing up by own or with
minimal assistance of nurses.
7. Walking without anyone
else’s intervention within a
small range of area eg. from
cabin to washroom.
4.Pain (Right hip)
Progression of joint
deterioration causing
chronic pain to his
Right hip
Identify 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
New medication
improving pain level.
Must maintain low level
dose twice per day to
keep on top of the pain.
Nigel needs some
encouragement to take
it.
Proper assessment of
pain and providing
appropriate medicine
regarding that is helpful.
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

5.Fluid &
Nutritional Deficits
Nigel reports of inability
to have a bowel
movement and
associated discomfort
Client will maintain
passage of soft, formed
stool every 1-3 days
without straining
1. Avoid eating food that
creates digestion problem.
Drinking sufficient amount of
water regularly before and
after meal.
2. Promote measures such as
 Regular time
 Routine daily time
 Provide stimulation eg
prune juice
 Allow adequate time
following meals
 Adequate exercise
3. Narcotic pain medicines can
create constipation issue.
Review of medication
process must be done by
expert.
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
Monitoring the fluid as
well as reviewing the
medication process
helped to get the pt to
her normal body weight.
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

6. Impaired skin
integrity
Ulcer on sacrum
Progressive healing of
tissues and no new
injuries
1. Reduce irritating moisture
Monitor client’s continence
status
 Monitoring wounded
area regularly
 Monitoring the vowel
function of the client
on a regular basis
 Use of mild cleansers
for cleaning
2. Improve tissue perfusion
Avoid pressure/massage on
reddened areas
 Avoid rubbing with
pressure
 Use of proper
antiseptic
 Changing of tissues
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
Pressure injury reducing
in size. Now size of 20c
piece, edges granulating
and only a small amount
of serous exudates.
In the morning time, the
changing as well as
repositioning of dressing
is very much effective to
prevent further pressure
ulcers and at the same
time it also assists to
prevent infection on the
wounds.
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

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:
 Use of proper
medication such as
antibiotics and
dressing the wounds
properly.
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

7. Risk for falls
Impaired balance as
evidenced by client
walking unsteadily,
asking for assistance,
need to urinate urgently
and frequently, uses
cane at home to
ambulate
Client will not experience
any falls during stay
1. Orient client to 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 door
open.
3. Toilet prior to bedtime,
awakening, 2/24 while awake
Lower bed height
No falls since admission.
Hazards in room
removed. Bathroom
door open at all times,
buzzer within reach
Assessment of hazards
in the wards, helped to
prevent the risk
associated with falls.
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

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.
Client will be able to
understand the spoken
word.
Client will sleep well
during night time hours.
1. Speaking in a slow
motion is required.
2. While talking with the
client, pronunciation must
be good and each
syllable will be clear.
3. Use of hand gestures to
make the client
understand clearly.
1. Required collaboration
with the analgesic nurse
regarding this.
2. Instead o using pillows,
special designed sleep
wedges can help to keep
the torso in a straight line
that relieves shortness of
breath.
3. Gentle tapping on the
joints to provide instant
relief of pain.
1. Mr Wheeler understands the
spoken word and participates
in communication with others.
2. The client was expressing his
needs and requirements by
communicating
3. Client was also showing
gestures and it helped in hand
movement also.
1. Client comfortably sleeps
2. Straightening up the torso
helps in sleeping quickly
3. Tapping on joints provided
relief and the client fall asleep
fast.
Communication helps
the patient to express
his requirements and
use of gestures
assists in body
movement.
Nurses’ intervention in
shortness of breath
and pain relief helps
the client to sleep
comfortably.
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