Nursing Care Plan
Student Version: Report, Project, Portfolio
| Student information | |||
| Student name: | Student ID: | ||
| Section A – Program/Course details | |||
| Qualification code: | HLT54115 | Qualification title: | Diploma of Nursing |
| Unit code:
| HLTENN013 | Unit title:
| Implement and monitor care of the older person |
| Section B – Assessment task details | |||||
| Assessment number: | 5 | Semester/Year: | 1/2020 | ||
| Due date: | Duration of assessment: | To be completed during your own time | |||
| Assessment task results: | This assessment task will be marked as: | ||||
| ☐ Ungraded result: Satisfactory or Not Satisfactory ☒ Other (eg points): Graded | |||||
| Section C – Instructions to students |
| Task instructions: |
| · This assessment can be answered as paragraphs using sub-headings. It does NOT have to be submitted in essay format. · This is an individual assessment. · This assignment must be submitted electronically viaTurnitin on Brightspace as a WORD document · You must keep a hard and soft copy of all work submitted · You must use APA 6 style to support your work · The laws of copyright meant that you cannot copy or cut and paste text from resource material without the appropriate attribution. Plagiarism is considered serious academic misconduct · Students must successfully complete all the answers to be deemed satisfactory in this assessment at a PASS grade. · Using the case study and additional information provided please complete all questions in the assessment
Case study Mr Tony Farnan is a ninety-three (93) years old male who resides at the Greenwood residential aged care facility in metro Victoria. He has lived here for three (3) years and prior to this he used to live alone at home. He had a close friend who used to visit him in the care facility. Once his friend got sick and stopped visiting him, Tony was finding himself becoming increasing socially isolated, anxious and finding it difficult to manage at the care facility.
Mr Farnan was never married and has no children. He used to work as a lawyer and has always taken pride in working independently and efficiently.
His past medical history includes:
– Atrial Fibrillation diagnosed 5 years ago and is having a pacemaker – TIA (Transient Ischemic Attack) diagnosed 1 year ago – Hypothyroidism diagnosed 10 years ago – Gout in both knees diagnosed 3 years ago – Severe depression diagnosed 4 years ago
He has more recently been diagnosed with Alzheimer’s dementia and urinary incontinence (urgency incontinence <12 months). He has absconded from the aged care facility twice since admission. Mr Farnan requires one staff to assist with personal care, including dental care (partial upper dentures).
Staff encourages him to attend social activities with other residents, however he tends to stay for only short periods and leaves the activity. Tony tends to wander around the facility and often forgets where his room is and requires staff to redirect and reorientate him often, several times a day. Staff have also noted that he is restless and wandering through the night, and spending time asleep during the day due to his night-time wandering. He is often seen distressed and crying at night time. Tony complaints that he has increasing pain in both his knees, however when asked about the pain he does not appear to be able to be to give accurate information to the staff and starts yelling. His answers often seem quite confused and vague.
He has had four (4) falls in last six (6) month, both resulting in nil injuries.
Tony can eat his meals with minimal staff assistance, however more recently the staff has noticed that he is eating less and at times forgets he is even there. He often refuses to attend dining area at mealtimes. He has had a recent weight loss over the last two (2) months of more than three (3) kgs, from 57.6 kgs to 54.6 kgs.
He refused to see a dietician on admission.
Medications:
Aspirin 100mg daily PRN Panadol 1gm TDS Voltaren Emulgel daily to right knee Endone 5mg PRN Tramadol PRN 10 mg Atenolol 100 mg mane Memantine 5mg daily Thyroxine 25mcg every day before breakfast
Current Situation (Morning Handover) 07:00 hrs:
You have been assigned to care for Mr Tony Farnan on a morning shift. Here is the handover you receive from the night staff:
Mr Farnan, in room 10, has been awake for periods overnight (almost 7 times). Staff checked on him at 01:00 hrs and they noticed he was screaming, and he was found sitting on the edge of his bed. Staff asked him what he was doing, and he replied that he was getting ready for catching the train to go to his home. Staff helped him to use the toilet and they noted that he was incontinent of urine and faeces. He was also noted limping while ambulating. Staff re-applied an incontinence aids, he was administered analgesics by the nurse post pain assessment, and he was assisted back to bed. He seemed quite confused and required reassurance that it was time for bed. He kept asking for going back to his home and cried for 30-45 mins.
Staff then noticed him up at 03:00 hrs and he required redirection to his bed. He was very confused and was found putting his day clothes on. At the time of report, he was having a shower with the night personal carer as he was up and at the nurses’ station requesting to go to the shops so he can prepare breakfast for himself. He was quite upset this morning stating that he was looking for his mother, who left him at the facility.
1) Medical diagnosis: Using the information you have been provided with describe the persons past medical history. Include the impact that this past medical history may/will have on the person.
2) Theory of ageing: Using the information you have been provided with and by doing further research determine which theory of ageing you believe is most appropriate for this person. Provide justification for your response.
3) Physiology of ageing: Using the information you have been provided with, explain the physiology of ageing and how it relates to this person’s disease process.
4) Primary health services: Identify which primary health services you believe would be appropriate for this person. Justify your response. You must identify at least two (2) primary health services that are appropriate for this person.
5) Strategies and Interventions for dementia/challenging behaviours: Describe at least four (4) strategies or interventions that you may be able to utilise to assist care for an individual with dementia. Ensure that you have linked this back to the person in the case study (what behaviours have you identified in the case study that would need to be managed? and what could be some of the triggers that might contribute to challenging behaviours?). Include physical pain as a trigger and communication strategies in your answer.
6) Oral hygiene: Using the information you have been provided with, identify why this person may be at risk for not having their oral hygiene needs met. What strategies could be implemented to ensure that this person’s oral hygiene needs are met?
7) Pain: Using the information you have been provided with, identify how you would determine if this person was in pain. What may cause this person pain? How would you manage this person’s pain?
8) Complementary therapies: Using the information provide identify any two (2) complementary therapies that you think this person may benefit from. Justify your response.
9) Nursing care plan: Using the attached nursing care plan, fill in the blank spaces for Mr Farnan. When developing goals please ensure they are SMART goals. Any actions must be nursing actions. You must have one (1) nursing action for each problem identified. When evaluating outcomes please be sure to include time frames.
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| Section D – Conditions for assessment | |
| Conditions: Student to complete and attach Assessment Cover Sheet to the completed Assessment Task. | |
| § This is an individual assessment that will be completed over the unit. The pre class work, tutorials and clinical laboratories for each week will support the student to complete the assessment. § This assessment is worth 100% of your final grade for this unit § There is no minimum word count, the maximum word count is 2500. § Discuss with your assessor if you feel you require special consideration or adjustment for this task § You must meet all the conditions in the marking guide to achieve a satisfactory outcome in this task. § You must pass all the questions in order to pass the assessment, grades will then be allocated § If you fail an assessment, your progress will be reviewed and eligibility for a resubmission will be determined by the Unit Teacher/Education Manager as per department policy listed in the Learner Handbook § If your work is marked ‘unsatisfactory’ and you are eligible for a resubmission yu may resubmit this task within the enrolment period as per Holmesglen assessment Policy § You may appeal the assessment decision according to the Holmesglen Assessment Policy § Where relevant, remediation may be offered prior to a resubmission · A student who successfully passes a resit shall be awarded a Pass (50%) mark. § | |
| Equipment/resources students must supply: | Equipment/resources to be provided by the RTO: |
| § Computer | § Assessment |
| Section E – Marking Guide | |||
| Assessment number: | 5 | Assessment title: | Nursing Care Plan |
| Student ID: | ID. | Student name: | Student name. |
| Unit code: | HLTENN013 | Unit title: | Implement and monitor care of the older person |
| Date: | Click here to enter a date. | ||
| Criteria for assessment | Satisfactory | Comment | ||
| Yes | No | |||
| The following has been submitted for assessment: | ||||
| The assignment must be submitted via Brightspace in WORD format | ☐ | ☐ | Click here to enter text. | |
| Marking criteria for each product document/s supplied. | ||||
| Question 1 Element 1. Respond to the health requirements of an older person. Performance criteria 1.2, 1.9 Knowledge Evidence: chronic age-related health problems | ||||
| 1. | Medical diagnosis – Using the information you have been provided with describe the persons past medical history. Include the impact that this past medical history may/will have on the person. | |||
| Pass Accurate description of medical history. Accurate description of how medical history will impact on person. Correct grammar, spelling and paraphrasing 4 Marks | ☐ | ☐ | ||
| Credit Accurate description of medical history. Accurate description of how medical history will impact on person. Correct grammar, spelling and paraphrasing. 5 Marks | ☐ | ☐ | ||
| Distinction Accurate description of medical history. Accurate description of how medical history will impact on person. Logical and insightful discussion Correct grammar, spelling and paraphrasing. 6 Marks | ☐ | ☐ | ||
| High Distinction Accurate description of medical history. Accurate description of how medical history will impact on person. Logical and insightful discussion Correctly referenced (including on reference page) Correct grammar, spelling and paraphrasing. 8 Marks | ☐ | ☐ | ||
| Question 2 Element 1. Respond to the health requirements of an older person. Performance criteria 1.6 Knowledge Evidence: theories of ageing, | ||||
| 2. | Theory of ageing – Using the information you have been provided with and by doing further research determine which theory of ageing you believe is most appropriate for this person. Provide justification for your response. | |||
| Pass Theory of ageing relevant to person 5 Marks | ☐ | ☐ | ||
| Credit Theory of ageing relevant to person Correct grammar, spelling and paraphrasing. 5 Marks | ☐ | ☐ | ||
| Distinction Theory of ageing relevant to person Logical and insightful discussion Correct grammar, spelling and paraphrasing. 6 Marks | ☐ | ☐ | ||
| High Distinction Theory of ageing relevant to person Logical and insightful discussion Correctly referenced (including on reference page) Correct grammar, spelling and paraphrasing. 8 Marks | ☐ | ☐ | ||
| Question 3 Element 1. Respond to the health requirements of an older person. Performance criteria 1.3, 1.9 Element 3. Apply nursing practice in the aged care environment. Performance criteria 3.4 Knowledge Evidence: physiology of the ageing process as it relates to disease processes | ||||
| 3. | Physiology of ageing: Using the information you have been provided with, explain the physiology of ageing and how it relates to this person’s disease process | |||
| Pass Physiology of ageing accurately described and relevant to person 5 Marks | ☐ | ☐ | ||
| Credit Physiology of ageing accurately described and relevant to person Correct grammar, spelling and paraphrasing. 5 Marks | ☐ | ☐ | ||
| Distinction Physiology of ageing accurately described and relevant to person Logical and insightful discussion Correct grammar, spelling and paraphrasing. 6 Marks | ☐ | ☐ | ||
| High Distinction Physiology of ageing accurately described and relevant to person Logical and insightful discussion Correctly referenced (including on reference page) Correct grammar, spelling and paraphrasing. 8 Marks | ☐ | ☐ | ||
| Question 4 Element Knowledge Evidence: counselling and support services and resources in the aged care environment and wider community, primary health care and services for the older person, strategies to respond to challenging behaviour including: distraction such as reminiscing, walking and listening to music, behaviour modification | ||||
| 4. | Primary health services: Identify which primary health services you believe would be appropriate for this person. Justify your response. You must identify at least two (2) primary health services that are appropriate for this person. | |||
| Pass Two (2) primary health care service appropriate for person
2 Marks | ☐ | ☐ | ||
| Credit Two (2) primary health care service appropriate for person Correct grammar, spelling and paraphrasing. 2.5 Marks | ☐ | ☐ | ||
| Distinction Two (2) primary health care service appropriate for person Logical and insightful discussion Correct grammar, spelling and paraphrasing. 3 Marks | ☐ | ☐ | ||
| High Distinction Two (2) primary health care service appropriate for person Logical and insightful discussion Correctly referenced (including on reference page) Correct grammar, spelling and paraphrasing. 4 Marks | ☐ | ☐ | ||
| Question 5 Element 1. Respond to the health requirements of an older person. Performance criteria 1.9 Element 2. Contribute to the care plan for an older person. Performance criteria, 2.7 Element 5. Use strategies that relate to the progressive and variable nature of dementia. Performance criteria 5.1 Element 6. Develop and implement strategies to minimise impact of challenging behaviours. Performance criteria 6.1, 6.2, 6.3 Knowledge Evidence: physical triggers for behaviour including pain and not wearing the prescribed hearing aids or alternative listening devices, the importance of a safe, physical, social and emotional environment for all older people and particular people with dementia | ||||
| 5. | Strategies and Interventions for dementia/challenging behaviours: Describe at least four (4) strategies or interventions that you may be able to utilise to assist care for an individual with dementia. Ensure that you have linked this back to the person in the case study (what behaviours have you identified in the case study that would need to be managed? and what could be some of the triggers that might contribute to challenging behaviours?). Include physical pain as a trigger and communication strategies in your answer. | |||
| Pass Two (2) strategies appropriate for a person with dementia. Pain as a trigger and communication as a strategy included in answer 6 Marks | ☐ | ☐ | ||
| Credit Three (3) strategies appropriate for a person with dementia. Pain as a trigger and communication as a strategy included in answer Correct grammar, spelling and paraphrasing. 5 Marks | ☐ | ☐ | ||
| Distinction Four (4) strategies appropriate for a person with dementia. Pain as a trigger and communication as a strategy included in answer Correct grammar, spelling and paraphrasing. 6 Marks | ☐ | ☐ | ||
| High Distinction Four (4) strategies appropriate for a person with dementia. Pain as a trigger and communication as a strategy included in answer Correctly referenced (including on reference page) Correct grammar, spelling and paraphrasing. 8 Marks | ☐ | ☐ | ||
| Question 6 Element 1. Respond to the health requirements of an older person. Performance criteria 1.8 Knowledge Evidence: oral hygiene for a partial or fully edentulous person including: care of dental prosthetics, screening for oral health conditions soft tissue care | ||||
| 6. | Oral hygiene: Using the information you have been provided with, identify why this person may be at risk for not having their oral hygiene needs met. Identify two (2) strategies that could be implemented to ensure that this person’s oral hygiene needs are met? | |||
| Pass Correctly identifies why person is at risk for not having oral hygiene needs met Correct identifies one (1) strategy to meet oral hygiene needs 4 Marks | ☐ | ☐ | ||
| Credit Correctly identifies why person is at risk for not having oral hygiene needs met Correct identifies one (1) strategy to meet oral hygiene needs Correct grammar, spelling and paraphrasing. 5 Marks | ☐ | ☐ | ||
| Distinction Correctly identifies why person is at risk for not having oral hygiene needs met Correct identifies two (2) strategies to meet oral hygiene needs Correct grammar, spelling and paraphrasing. 6 Marks | ☐ | ☐ | ||
| High Distinction Correctly identifies why person is at risk for not having oral hygiene needs met Correct identifies two (2) strategies to meet oral hygiene needs Correctly referenced (including on reference page) Correct grammar, spelling and paraphrasing. 8 Marks | ☐ | ☐ | ||
| Question 7 Element Knowledge Evidence: | ||||
| 7. | Pain: Using the information you have been provided with, identify how you would determine if this person was in pain. What may cause this person pain? How would you manage this person’s pain? | |||
| Pass Accurate description of how to identify pain Accurate description of why this person may be in pain Accurate description of how to manage this person’s pain 4 Marks | ☐ | ☐ | ||
| Credit Accurate description of how to identify pain Accurate description of why this person may be in pain Accurate description of how to manage this person’s pain Correct grammar, spelling and paraphrasing. 5 Marks | ☐ | ☐ | ||
| Distinction Accurate description of how to identify pain Accurate description of why this person may be in pain Accurate description of how to manage this person’s pain Logical and insightful discussion Correct grammar, spelling and paraphrasing. 6 Marks | ☐ | ☐ | ||
| High Distinction Accurate description of how to identify pain Accurate description of why this person may be in pain Accurate description of how to manage this person’s pain Logical and insightful discussion Correctly referenced (including on reference page) Correct grammar, spelling and paraphrasing. 8 Marks | ☐ | ☐ | ||
| Question 8 Element Knowledge Evidence: complementary therapies | ||||
| 8. | Complementary therapies – using the information provided, identify any two (2) complementary therapies that you think this person may benefit from. Justify your response. | |||
| Pass Correctly identifies two (2) complementary therapies. 2 Marks | ☐ | ☐ | ||
| Credit Correctly identifies two (2) complementary therapies Correct grammar, spelling and paraphrasing. 2.5 Marks | ☐ | ☐ | ||
| Distinction Correctly identifies two (2) complementary therapies Logical and insightful discussion Correct grammar, spelling and paraphrasing. 3 Marks | ☐ | ☐ | ||
| High Distinction Correctly identifies two (2) complementary therapies Logical and insightful discussion Correctly referenced (including on reference page) Correct grammar, spelling and paraphrasing. 4 Marks | ☐ | ☐ | ||
| Question 9 Element 1. Respond to the health requirements of an older person. Performance criteria 1.9 Element 2. Contribute to the care plan for an older person. Performance criteria 2.1, 2.4, 2.7 Element 3. Apply nursing practice in the aged care environment. Performance criteria 3.4 Element 5. Use strategies that relate to the progressive and variable nature of dementia. Performance criteria 5.1, 5.3 Knowledge Evidence: the potential impacts of dual or multiple diagnoses on identification and prioritisation of the older person’s needs, nature of dementia as a progressive neurological condition, and strategies and nursing interventions that can be used with people with dementia, strategies to respond to challenging behaviour including: distraction such as reminiscing, walking and listening to music, behaviour modification | ||||
| 9. | Nursing care plan: Using the attached nursing care plan, fill in the blank spaces for Mr Farnan. When developing goals please ensure they are SMART goals. Any actions must be nursing actions. You must have one (1) nursing action for each problem identified. When evaluating outcomes please be sure to include time frames. | |||
| Pass 5-7 areas completed correctly and related to case study 4 Marks | ☐ | ☐ | ||
| Credit 7-9 areas completed correctly and related to case study 5 Marks | ☐ | ☐ | ||
| Distinction All 10 areas completed correctly and related to case study. 6 Marks | ☐ | ☐ | ||
| High Distinction All 10 areas completed correctly and related to case study. Correctly referenced (including on reference page) Correct grammar, spelling and paraphrasing 8 Marks | ☐ | ☐ | ||
| Total marks for assignment | /64 | |||
| (Enrolled Nurse Standards for Practice (2016) Assessed: 1.3, 2.3, 4.2, 8.2, 8.4) | ||||
| Identify problems/issues | Establish Goals (using SMART format) | Take Action | Evaluate Outcomes (how will you know your actions have worked? Included time frames) |
| Potential:
Risk for fall secondary to gout and dementia as evidenced by confused and issues with mobility and history of falls
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By the end of the week, pt will be assisted with mobility and supervised with all the activities to prevent falls.
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| Potential:
Potential for acute confusion/ delirium secondary to urinary incontinence and dementia |
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| Actual:
Pain in B/L knees secondary to gout and past falls as evidenced by complaints of knee pain while mobilization
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Pain assessment (Abbey pain scale)
DBE Non-pharmacological support
Analgesics
Assistance with mobility |
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| Actual:
Self-care deficit secondary to ageing and dementia as evidenced by pt finding it hard to perform ADL’s
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| Section F – Feedback to Student | ||
| Has the student successfully completed this assessment task? | Yes | No |
| ☐ | ☐ | |
| Additional Assessor comments (as appropriate): | ||
| Resubmission allowed: | Yes ☐ | No ☐ | Resubmission due date: | |
| Assessor name: | ||||
| Assessor signature: | ||||
| Date: | ||||