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Health Assessment Nursing Care Plan Workbook

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Health Assessment Nursing Care Plan Workbook

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Health Assessment Nursing Care Plan Workbook

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Discuss About The Health Assessment Nursing Care Plan Workbook.
Are The Nursing Actions Needed To Achieve The Goal?


In Assessment Task 2 –Part B you are required to complete a comprehensive healthcare assessment and nursing care plan on information given to you in the case study- Mr. Kevin Jones. The case study information is located in the Book – Case Study Guidelines for Assessment Task 2 (B).
Using the information gathered from the case study of Mr. Kevin Jones, you are expected to document the assessment you have undertaken. You are also asked to identify four (4) priority issues, develop, implement and evaluate your nursing care plan for Mr. Kevin Jones.  All information is to be recorded in this Health Assessment & Nursing Care Plan Workbook. Your completed Health Assessment & Nursing Care Plan Workbook will be assessed using the marking guide in the NURBN2000 Moodle shell. Print a copy of the marking guide and keep it with you while writing your Care Plan to ensure you answer the questions correctly.
Guidelines for Health Assessment and Nursing Care plan (Total: 2000 words)

This assessment relies on students being familiar with the nursing process as you will be required to follow the steps outlined in this process. If you are not familiar with this, review in any recommended nursing textbook – however, this has been covered in your prior EN training.
Complete the workbook, ensuring you have answered all the questions
Students will demonstrate clinical decision making skills in:

The Nursing Process.

Identification/ assessmentof nursing problems (nursing diagnosis)
Planning andImplementation of nursing care
Documentationof nursing data.
Evaluationof nursing care

Read this plan for the assessment task:

Activity-Assessment Task 2: Total 2000 words

600 word assessment
Nursing Care Plan
3 Diagnosis/Problems
Expected outcomes

Referenced 600 word assessment identifying physical & mental health components e.g. dehydration may result in anxiety & confusion (Gulanick & Myers, 2012)
Remaining word count utilised in the rest of document (1400 words)
Your care planning will be based on your assessment data
Develop a Care Plan based on data gathered in your assessment (a,b,c). Then, identify three (3) main nursing problems and provide goals, interventions, rationale and implementation of that care.

Evaluate (how successful was the care for each of the 3 problems identified)

Submit Workbook

Adult Health Assessment – Total: 2000 words

Students are required to discuss the physical and mental health components for the assessment(600 words). This will need to be written & referenced according to academic writing & referencing standards.
Identify 4 majorissues for Kevin Jones, his social history and provide a summary of your overall assessment of him. Ensure that you use ‘objective’ language. This would be similar to what you would write in nursing notes as an admission history.
Using the Nursing diagnosis section, select the three (3) health nursing diagnosisthat you think are a priority for Kevin and include the evidence from your assessment that supports this.
Now prioritise these 3 important Nursing problemsto formulate a nursing care plan for Kevin
Develop a nursing care plan with rationale (referenced) and related interventionsthat could be implemented for Kevin.
Complete the evaluation sectionsof the care plan – identify ways that you could measure success in relation to each of these interventions.

Write your 600 word referenced assessment below discussing the physical and mental health components for Kevin. This will need to be written according to academic writing & referencing standards.(NB: your assessment will roll into the next page).
The current study takes into consideration the case history of Kevin Jones who is a 75 year old man receiving health and support care services. Mr. Kevin was a  widower living alone since the last 13 years. In this respect, the past history of the patient need to be focused upon where the  patient  Mr. Kevin had  suffered from multiple health  issues such as prostate enlargement, hypertension, alcoholism, depression and anxiety. Recently the patient had suffered from cerebrovascular accident (CVA) which has resulted in right side paralysis. Therefore, during walking or movement the patient seems to bend over to one side more. Kevin also cannot speak clearly as his speech often becomes blurred, which disables him to express himself clearly, which results in an emotional outburst in the patient.
Kevin being an independent man wants to live on his own and not be dependent upon the support and care providers. These results in regular confrontation of the patient with the care and support service providers where the patient does not want to follow the advice of the support carers. The patient depicts high levels of anxiety and wants to return home. Some of the clinical conditions of the patient could be described as follows such as presence of chronic cough with chills and fever. The patient   also complained of body ache along with loss of appetite.  Some of the vital signs of the patient were noted for designing of an effective clinical care. The patient depicted a body temperature of 38.3 degree centigrade which was slightly above normal. The patient recorded a blood pressure of 90/60, a respiratory rate of 24 breaths per min, pulse noted at 90 and the partial pressure of oxygen noted at 93%. The chest x-ray of the patient revealed that the patient had pneumonia   in the lower lobe. Kevin also suffered from swallowing difficulties, which resulted in the patient suffering from dehydration. The patient seems to be suffering from dehydration which made his skin turgor and mucous membranes dry (Castellan, Sluga, Spina & Sanson, 2016). The patient had decreased urine output and increased urine concentration and has elevated levels of blood urea level. Kevin had erratic and hard bowels and suffered from occasional urine  incontinence. Additionally, antibiotics could be used for the treatment of pneumonia in the patient such as ceftriaxone and   azithromycin etc (Call et al., 2016).
Therefore, depending upon the signs and symptoms expressed by the patient the physical and mental components of care could be designed for the patient.
Based upon the cumulative health conditions of the patient, the nursing priorities which could be designed for the patient are- restoring the hydration capacity in the patient and treating of lower lobe pneumonia. As mentioned by Doenges, Moorhouse & Murr (2016), less water intake has been associated with reduced metabolism and less kidney function. In order to track the dehydration the patient needs to be put in an effective hydration therapy. The electrolyte and fluid balance within the patient could be restored with the help of channel IV therapy. The patient Kevin suffered from pneumonia   resulting in coughing in the patient, which could possibly block the airway resulting in swallowing difficulties.

(a) Identify 4 Key Health Issues/ problems for nursing care

– pneumonia 


— urine incontinence

– depression

Document Kevin’s social history
Mr. Kevin is a 75 year old widower man and lives in a rural location and is the father of three kids. Two of his children live outside Victoria and his middle son lives nearby but cannot give sufficient time to his father owing to his busy schedule. Kevin had been suffering from multiple physical and mental health issues which has challenged his autonomy over his daily life. 
Summary of overall assessment for Kevin
The priority based care which should be undertaken in the client is   the management of the lower lobe pneumonia in the patient. Some of the  protocols  which  could   be followed in the patient are  putting the  patient on oxygen  therapy which could help  in restoring the  partial pressure of  oxygen (Coleman, Levy, Wiggins & Kinley, 2017).  In case the patient complained of shortness of breath venturi masks could be supplied to the patient to help the patient with the breathing process.
Due to the deteriorating the physical health in the patient Mr. Kevin, the patient increasingly suffered from anxiety and depression. The depression made the patient suffer from emotional bursts at times. The patient was uncanny and wanted to return home as he was a farmer by profession and was worried about his pet flocks and the crops   which were being nurtured by his son for a while.  The patient also became infurious towards the support carers who were responsible for looking after the patient. Therefore, therapeutic communication approaches and emotional counselling could help in relieving the traumatised condition of the patient (Davidson & Everett, 2015)
Identifying Nursing Problems (Diagnosis)
Nursing Diagnosis
A nursing diagnosis is a statement that describes the PERSON’S actual or potential response to a health problem that requires nursing care. It is a three part statement with diagnosis, cause and evidence.
Ref: Berman, A., Snyder, S., J., Levett-Jones, T., Dwyer, T., Hales, M., Harvey, N. Luxford, Y., Moxham, L., Park, T., Parker, B., Reid-Searl, K., Stanley, D. (2014).  Kozier & Erb’s Fundamentals of Nursing (3r Australian Ed.). Pearson: NSW, Australia. 2012, Ch. 13 Page 233 -249
Based on Assessment data you have gathered, select the three (3) priority diagnoses that you feel are the most appropriate for Kevin.
Ensure you include what evidence you have to support this.
Based  upon the  patient data   three  nursing care priorities  have been designed  for the patient which are –  treatment  of  pneumonia,  dehydration management in the patient,  tre
Health Assessment Nursing Care Plan Workbook
atment of urine incontinence.
 (1) Diagnosis: on conducting a   chest x-ray, the patient was diagnosed of lower lobe pneumonia
Cause: the cause of the pneumonia may be due to infection by bacteria, viruses and other pathogens. The infection could be trigged due to random exposure to the pathogens or predisposition to practices such as alcoholism which results in inflammation of the lungs or could serious lung diseases (Müller, 2015).
Evidenced by:  Breathing pattern ineffective, risk for development of pneumonia.
(2) Diagnosis: the patient had dry and flushed skin along with hard bowels which indicated dehydration in the patient
Cause- the patient had swallowing difficulties attributed to the cough which made swallowing difficult for the patient. Hence, the patient was drinking less water  which made the  skin of the patient flush as well as the patient had erratic and  hard bowels.
Evidenced by: Fluid volume deficient risk for dehydration
(3) Diagnosis- the patient was diagnosed with urine incontinence 
Cause – the cause of the urine incontinence was inadequate drainage by the patient, as the patient was drinking less water. This was further represented in the form of hard and erratic stools by the patient.
Evidenced by: Urine incontinence risk for functional impairment in the patient.
Nursing Care Plan (Berman et al, 2012, Ch. 13 Page 233 -273)
To develop the Nursing Care Plan:

Critically analyse, cluster and validate your assessment data for Kevin into the following format:-
Include three(3) nursing problems diagnosis with Goals (outcomes), Nursing Interventions, Rationales (reasons)
Write clear statements that clearly reflect the problem. You may use your own wording.
You may use the health patterns cluster statements below to assist you identify a nursing diagnosis, or you may use ones that reflect the individual client.

Goals or expected outcomes
Have a time frame and are realistic outcomes related to the nursing diagnosis.
Are the nursing actions needed to achieve the goal?
Rationale (must be referenced)
The reasons for nursing interventions are recorded in detail.
Determines if nursing interventions are effective and goals have been achieved.  
Evaluation consists of:

Collection of data related to outcomes
Comparison of this data with predicted outcomes
Revision of nursing actions to goals and or outcomes
Drawing conclusions about problem status and then continuing, modifying or terminating the care plan
Documenting changes in nursing interventions and outcomes

Now continue to the Nursing Care Plan below and enter your data

Nursing diagnosis: 1
(Nursing Problem)

 Lower lobe pneumonia

Evidenced by

Breathing pattern ineffective , risk for development of  pneumonia (, 2018)

Goal & time frame

The patient to be provided with a comprehensive therapy which will help in effective treatment of the lower lobe pneumonia in the patient. The treatment results are to be obtained within a month’s time, where the patient is free of the pneumonia.

Nursing Interventions. (actions to address the problem)

Write nursing interventions here
 The nursing interventions which  could  be taken to address the problem of  pneumonia  within  the patient  Mr. Kevin has been enlisted over here such as-
· Access the rate and depth of  respirations and chest movements
· Noting  areas of decreased and absent air flow such as crackles and wheezes (Pascoal et al., 2015)
· Changing   position of  bed frequently
· Assisting the   patient with proper breathing
· Forcing of  warm liquids to at least 300 ml/day
· Administration of medications such as  expectorants and bronchodilators (Beloncle & Mercat, 2018)

Rationale: (reasons) – References needed to validate nursing interventions
A number of interventions could be suggested over here in order to provide effective treatment for pneumonia to the patient. As mentioned by Pascoal  et al. (2016), the deep breathing exercises can help in mobilizing of the cough in the patient.  The forcing in of warm liquids helps in mobilization of the cough. The expectorants help in reduction of the bronchospasm (Beloncle & Mercat, 2018).  The tilting of the head or changing of the bed positions can help in airway clearing.

Evaluation of Care (how successful were the interventions)
The interventions were further evaluated for their rate of success. Some of the methods such as use of expectorants have been found to be beneficial in clearing of the cough from the chest of the patient. The infusion of warm liquid has been seen to effectively mobilize the cough in the patient and reduce bronchospasm.  As argued by Coleman, Levy, Wiggins & Kinley (2017), the deep breathing exercises have been seen to reduce the bronchospams within the patient.

Nursing diagnosis: 2
(Nursing Problem)


Evidenced by

Fluid volume deficient risk for dehydration (, 2018).

Goal & time frame

The hydration within the patient to be restored within a ten to fifteen days time.

Nursing Interventions (actions to address the problem)

Write nursing interventions here
The nursing  interventions for dehydration  can  be enlisted  through a number of steps such as –
· Assessment of  skin turgor  and oral mucous membranes for signs of  dehydration
· Monitoring BP for  orthostatic changes
· Assessment of colour and amount  of urine (Miller, 2017)
· Monitoring of  urine  osmomolality (Li, He, Ying & Hahn, 2014)
· Assessment of  alteration in mentation

Rationale: (reasons) – References needed to validate nursing interventions
The above nursing interventions help in evaluating the condition of the patient. As mentioned by Li, He, Ying & Hahn (2014), fluid loss can be measured with the help of postural hypotension. This is further signified by a 20 mm Hg drop in systolic pressure and a 10 mm Hg drop in diastolic pressure. The orthostatic   hypotension followed by volume depletion also results in increased heart rate

Evaluation of Care (how successful were the interventions)
Some of the intervention methods when applied with Mr. Kevin were successful in regulating and management of the symptoms of the dehydration in the patient.  For example. Measuring the Bloor pressure of the patient on a three to six hourly basis along with studying the urine concentration and gravity helped in analysing the dehydration standards in the patient. Additionally, use of tools such as Glasscow scale can also help in assessment of the mental awareness levels of the patient.

Nursing diagnosis: 3
(Nursing Problem)

Urine incontinence  

Evidenced by

Urine incontinence  risk for functional impairment in the  patient (, 2018).

Goal & time frame

The patient to be relieved of the symptoms of urine incontinence within a week’s time.

Nursing Interventions (actions to address the problem)

Write nursing interventions here
A  number of  nursing interventions could d be designed  for treatment of the urine  incontinence   in the patient such as-
· Taking detailed records of  frequency and severity of  leakage episodes (Wagg et al., 2015)
· Assessment of the  patient’s  recognition of the  need to void
· Looking for treatment methods to reverse the underlying cause

Rationale: (reasons) – References needed to validate nursing interventions
A number of steps or measures need to be taken for management of urine incontinence within the patient. Some of these have been evaluated   with the respect to the current situation.
As mentioned by Gershman  et al. (2015), investigation of the sole underlying causes can help in enhancing the recovery rate. For the process of which detailed physical examination of the patient needs to be conducted. Additionally, analysing the frequency and severity of leakage can help in designing of an effective treatment plan.

Evaluation of Care (how successful were the interventions)
Some of the methods adopted for the urine incontinence management of the patient had been further evaluated over here. For example, reversing the cause of the infection has been seen to reduce the severity of the disease. In the present context, the patient had been suffering from dehydration which resulted in erratic bowels syndrome in the patient. This   further   worsened the urine incontinence present in the patient. Additionally, score obtained through psychometric assessments were bencificial in estimating the mental awareness levels of the patient in responding to functional continence.

Start your references on the next page
Beloncle, F., & Mercat, A. (2018). Approaches and techniques to avoid development or progression of acute respiratory distress syndrome. Current opinion in critical care, 24(1), 10-15. doi: 10.1097/MCC.0000000000000477
Call, S. M., Pujol, A. G., Chacón, E. J., Martí, L. H., Pérez, G. T., Gómez, V. S., … & Vaquer, S. A. (2016). Individualised care plan during extracorporeal membrane oxygenation. A clinical case. Enfermeria intensiva, 27(2), 75-80. DOI: 10.1016/j.enfi.2015.12.002
Castellan, C., Sluga, S., Spina, E., & Sanson, G. (2016). Nursing diagnoses, outcomes and interventions as measures of patient complexity and nursing care requirement in Intensive Care Unit. Journal of advanced nursing, 72(6), 1273-1286. Retrieved from:
Coleman, J., Levy, J., Wiggins, S., & Kinley, J. (2017). Using a new end-of-life care plan in nursing homes. Nursing And Residential Care, 19(1), 38-41. Retrieved from:
Davidson, P., & Everett, B. (2015). Managing approaches to nursing care delivery. Transitions in nursing: preparing for professional practice. Chatswood, New South Wales, Australia: Elsevier Health Sciences, 125-142. Retrieved from:,+P.,+%26+Everett,+B.+(2015).+Managing+approaches+to+nursing+care+delivery.+Transitions+in+nursing:+preparing+for+professional+practice.+Chatswood,+New+South+Wales,
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: guidelines for individualizing client care across the life span. FA Davis. Retrieved from:,+M.+E.,+Moorhouse,+M.+F.,+%26+Murr,+A.+C.+(2014).+Nursing+care+plans:+guidelines+for+individualizing+client+care+across+the+life+span.+FA+Davis&ots=v5QHOECHqs&sig=CHkp04hbq-g6cUt6O0N5VV5Okyg&redir_esc=y#v=onepage&q&f=false
Gershman, B., Eisenberg, M. S., Thompson, R. H., Frank, I., Kaushik, D., Tarrell, R., … & Boorjian, S. A. (2015). Comparative impact of continent and incontinent urinary diversion on long?term renal function after radical cystectomy in patients with preoperative chronic kidney disease 2 and chronic kidney disease 3a. International Journal of Urology, 22(7), 651-656. Retrieved from:
Li, Y., He, R., Ying, X., & Hahn, R. G. (2014). Dehydration, hemodynamics and fluid volume optimization after induction of general anesthesia. management, 69(12), 809-816. Retrieved from:
Miller, C. G. (2017). Dehydration in Nursing Home Residents: A meta-analysis of causes of dehydration, implications, and those most at risk. Retrieved from:
Müller, F. (2015). Oral hygiene reduces the mortality from aspiration pneumonia in frail elders. Journal of dental research, 94(3_suppl), 14S-16S. Retrieved from: (2018), , Retrieved on 13 May 2018, from
Pascoal, L. M., Lopes, M. V. D. O., Silva, V. M., Beltrão, B. A., Chaves, D. B. R., Nunes, M. M., & Castro, N. B. (2016). Prognostic clinical indicators of short?term survival for ineffective breathing pattern in children with acute respiratory infection. Journal of clinical nursing, 25(5-6), 752-759. Retrieved from:
Wagg, A., Gibson, W., Ostaszkiewicz, J., Johnson, T., Markland, A., Palmer, M. H., … & Kirschner?Hermanns, R. (2015). Urinary incontinence in frail elderly persons: Report from the 5th International Consultation on Incontinence. Neurourology and urodynamics, 34(5), 398-406. Retrieved from:

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