HLTENN004 Implement, Monitor And Evaluate Nursing Care Plans


Task instructions:

Part A

Medical diagnosis – using the information you have been provided with describe the presenting problem (description of the medical diagnosis which has resulted in them being admitted into hospital) for the individual in the case study.  Then identify any past medical history for this individual.  Include the impact this medical diagnosis and past medical history will have on the individual.

Age of individual – using the information you have been provided with explain how the individual’s age may/will impact their ability to meet their activities of daily living.  You should consider their medical diagnosis in your answer.

Preparation for procedures – using the information you have been provided with describe how you would prepare this person for a procedure.  You should consider their age and medical diagnosis in your answer.

Privacy and dignity – using the information you have been provided with explain how you will maintain this individual’s privacy and dignity while caring for them.  You should consider their age, culture and gender in your answer.

Risk identification – using the information you have been provided with, discuss any risks that you have identified for this individual.  The may include the following:

~ age (e.g. How does age increase their risk of potential issues/problems and what are those problems?)

~ anaesthesia and surgery

~ cognitive status

~ deep vein thrombosis, venous thromboembolism, pulmonary embolism

~ immobility

~ length of stay

~ mental health condition

~ non-compliance

~ nutritional status

~ pain

~ presence of morbidity

~ maintaining a safe environment, including risk prevention strategies.

Part B – Nursing care plan, based on the clinical reasoning cycle

Look, collect, process, decide, plan, act, evaluate and reflect. 

Your nursing care plan must include:

  1. Two (2) actual problems/issues including: how you will assist this person to meet their activities of daily living, and how you would manage pain and/or insomnia.
  2. Two (2) potential problems/issues and their management including potential problems that may occur due to immobility for this person

Case Study: Natia Euta

Progress Notes:


76-year-old female presented to emergency with R) sided headache, L) sided arm.—


weakness and vertigo. CT Brain scan performed.-


CT brain showedR) sided thrombolic CVA.Past Medical History (PMH) includes: Ht,


Obesity,TIA (2014),Type 2 DM and OA. Plan – admit to ward.  For speech


pathologist, physio and dietician r/v. -Dr Chen


Pt admitted to ward at 2350 on 20/09/2018 post R) CVA. L) sided arm weakness and


vertigo.On arrival to the ward,pt complaining of R) sided headache, pain 6/10. –


Analgesia as prescribed with nil relief, Dr Chen notified. Pt drowsy but rousable.GCS


12.PEARL 2+.  L) sided arm weakness, R) arm normal strength. Equallower limb


strength. HR 72,Regular, BP 162/80, SaO2 97% on room air. Respiratory rate 14.Pt


to remain NBM untilspeech path r/v. BNO (day 3). Incontinent of urine x2.Referrals


made to speech path, physio and dietician — S Kerns RN


R/V by speech pathologist. Pt to remain nil by mouth. Will require nasogastric feeding.


Pt to be reviewed in 1/7.- B.Patal


Pt has been r/v by speech. To have nasogastric tube inserted. Headache remains


6/10. Awaiting physio and dieticianr/v.  Will require admission to rehabilitation unit.  


Referral has been sent.  Awaiting bed. –Dr Chen


Nursing note am – Pt alert and orientated. Headache remains at 6/10, medications as


charted. Vital signs as charted. Pt wash in bed. Skin dry and intact. Awaiting


physio and dietician review. Nasogastric tube Inserted, awaiting X-ray confirmation


of placement prior to use. Family in attendance.–M Dus EN


X-ray confirms that the nasogastric is in correct position, okay for use. Please if


commence nasogastric feeds at 20mls/hr, then increase to 40mls/hr in 6 hours,


patient is tolerating feeds. –Dr Chen


Nursing notes pm – Pt alert and orientated. Pain from headache remains at 6/10. Pt


sitting up in bed. Vital and neuro obs as charted. Incontinent ofUrine. Skin excoriated.


Family in attendance. Awaiting rehab bed. – H Dymond RN


Pt has not slept overnight. Pt reports that this is due to pain and missing her husband


and feeling very scared. Pressure area care has been attended to and patient has


had a bed bath overnight in attempt to resettle her, with minimal effect. Excoriated


skin in perineal area cleaned and a barrier cream applied. Pt’s lack of sleep is to be


discussed with the Dr on the morning round. BGL pre-breakfast and was 6.2mmol/L.

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