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Nursing Assessment Questions – Implement, Monitor & Evaluate Nursing Care Plans

Subject: Nursing
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Question 1

Activities of Daily Living (ADL’s) include those routine activities of the people, which are essential for self-care. The six ADLs thus include “movement in bed”, “transfers” between seats or change in positions, etc, “locomotion”, “feeding”, “dressing” and maintaining “personal hygiene” (VRB, n.d.).

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Question 2a

The complaint of inability to sleep can be the symptoms of Insomnia. In this case, the first strategy would be to verify the extent, to which the client faces sleep-related problem and then to accordingly categorize and identify whether it is secondary insomnia, idiopathic insomnia or primary sleep disorders. The remedies to be suggested to ensure client’s comfort, rest and sleep thus depends on the gravity of the problem. In case the client is in the initial stage of insomnia, he/she needs to avoid sleeping during the day as well as drinking tea, caffeinated drinks, coffee and even smoking. Further, they can be suggested to stop exercise before bedtime and to meditate more and take a warm bath. Contextually, if the client is facing problem in sleeping for over years, it can be recommended that they opt for professional help, carry out the therapies to decrease insomniac behavior, expose themselves to morning sunlight, take medications on a regular basis and maintain a proper time-frame for sleeping (State of Victoria, 2018).

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Question 3a

The safety precautions to be undertaken for ensuring personal hygiene includes the habit of taking bath daily or at least wet-cloth sponging to wash the body, brushing daily to safeguard teeth from decay and gum disease and taking hair wash at least a day in a week. Safety precaution also includes washing hand with soap after toilet and before food preparation or before eating so as to wash off the germs as well as changing clothes and washing them on regularly. Besides, covering mouth and nose while sneezing can also be considered as a part of personal hygiene as it help to safeguard an individual from spreading germs through air (Victoria State Government, 2018).

Question 3b

As a professional care giver, it is essential to maintain the need, privacy and right of the patient, especially at the time of assisting them in toileting. For maintaining privacy and client dignity, it is important to understand that conversation on toileting needs must be conducted in an empty room or often in a space behind the curtains, where the client can feel comfortable. Moreover, it is important for a professional to respect their needs and take their consent prior to getting involved with the process. A friendlier approach is also required at such instances so that the patient does not feel awkward in sharing their personal problems and requirements with the respective professional (SA Health, 2016).

Question 3c

The information that needs to be documented on the care plan regarding personal hygiene entails daily interests of the patient (client) on a regular basis such as behavioral changes, mobility, communication skills and skin integrity. Along with this, gathering feedback from the client and writing reports are also documented on a care plan (“Personal care: reporting and documenting,” 2017).

Question 4

Physical comfort refers to the care provided to a client, which plays a significant role in promotion. The term comfort actually implies the outcome of the positive attitude due to psych spiritual, environmental and social dimensions. For the maintenance of a patient’s physical comfort, it is essential that the healthcare professional develop necessary knowledge, abilities and skills for being responsive towards identifying the client’s physical as well as emotional comfort. The strategies that can ensure client’s level of comfort include the following:

  • Encouraging the client to express their pain and discomfort
  • Determining the reason behind the discomfort
  • Taking immediate actions for enabling them to recover
  •  Providing them with alternative options for comfort
  • Maintaining the record of clients comfort position, managing noise and their privacy (Source: Williams, Lester, Bulsara, Petterson, Bennett, Allen.,… Joske, 2017)

Question 5

Urinary Incontinence refers to any accidental or involuntary leakage of urine. If the client is facing such problems, different strategies must be undertaken to reduce inconsistency. Initially, an assessment about client’s medical history is to be checked for estimating the number if time urine was passed, along with the details of fluid intake and diet, which also needs to be checked to ensure that the plan made is specific. Management and treatment of the client also include increasing fluid intake along with high-fiber diet, medication course, pelvic exercise, bladder training and use of incontinence pads (Better health, 2018).

Question 6

Urinary continence aids and products include catheters and tubes that can help the affected clients to lead a normal life. The considerations include that the right product is to be selected for the client’s use as there are various continence products in the market that can help the patient to stay comfortable and dry. For the right care, selection of the right product is vital. Furthermore, the client also needs to be assisted on making appropriate use of the product. Subsequently, the Urinary continence pads include pants, pads, tubes and catheters, which come in different sizes and shapes. Some of these products are reusable while the others must be disposed off, which should be explained to the client for ensuring proper care (Continence Foundation of Australia, 2018).

Question 7

The strategies to be consider in assisting a client has been discussed below:

Teeth Brushing: Explaining the client about what is to be done and the procedures of using gloves, towel under neck to protect clothes, moistening their brush applying toothpaste, thereby ensuring that the brushes are held in correct position encouraging them to brush their own teeth (“Dentures,” n.d.).

Care of Dentures: It needs to be planed as the client may face emotions of anger, denial and grief due to tooth loss. The denture after taking out from mouth is to be cleaned as it can build plaque (“Dentures,” n.d.).

Using Alcohol-Free Mouthwash: The client must be encourage to use mouthwash as it can reduce the leftover food particles in building plaque that can increase bad-mouth odor (“Dentures,” n.d.).

Interdental cleaning: It is suitable for dental flossing and disrupting biofilm to maintain effective oral health (“Dentures,” n.d.).

Question 8a

The specific point related to mobility assessment includes the following:

  • Incidental activity, which emphasizes the need and processes to encourage the client to dress themselves, allow them to move around the ward, encourage them to sit out of the bed whenever appropriate and to walk to the bathroom as and when required with assistance. These activities are practiced as the easiest exercises for clients in the hospital settings (Victoria State Government, 2018a).
  • Exercising in a group can also enable the client to socialize, thereby safeguarding them from loneliness (Victoria State Government, 2018a).
  • Retention of ADL further can help the client to live independently by developing the their necessary skills (Victoria State Government, 2018a).

Question 8b

The types of aids that can assist a client with mobility issue includes the assistance of independent living solutions such as shower chairs, wheelchairs, kettle tippers, mobility scooters, king modular button hook handle and many more. The use of these aids can thus help the client to walk, provides them with the required support to stand from a sitting position. For example, mobility scooter helps the client to move from one corner to the other and these encourage them in commencing physical activities (Maya, 2015).

Question 9

The nursing activities that should be included in a care plan related to respiration and circulation includes breathing exercise during physical activity. The care plan should include exercise, which can ensure that proper amount of air is transferred to lungs, thereby helping the client to develop the strength of clients diaphragm, help them with exercise to bring deep-seated mucous as well as to keep the chest wall and lungs moving (State of Victoria, 2018).

Question 10

The fluid overload is recognized by certain symptoms, which include increased daily weight, overt LVF, raised JVP and peripheral oedema. Pulmonary oedema further refers to the condition of the patient, when the fluid is overloaded in the air spaces and tissues of patient lungs. If the fluid is raised, the patient becomes sweaty, sits forward, and shows the symptoms of being hypoxic and dyspnoeic. The fluid deficit can also be recognized, when the client’s eyes become sunken, dry mucous membranes, weight loss as well as the lethargic conditions of the client. The fluid measurement is important to suggest appropriate diagnosis, so that the records can be made in I/O chart (The Royal Children’s Hospital Melbourne, n.d.).

Question 11

Nutrition is important for leading a healthy life. Physical activity and a nutritional diet can further help the client to reduce chronic diseases and continue a healthy weight. The risk factors include type 2 diabetes along with hypertension and especially deficit in the nutrition level of an elderly person. They can even suffer from loss of weight and muscles mass, as well as inappropriate BMI. Therefore, they should be systematically screened so as to monitor and maintain their health conditions and prevent themselves from adverse medical problems such as hospitalization, morbidity, frailty and mortality (National Health and Medical Research Council, 2015).

Question 12

The process to access client pain will involve clinical judgment that will be based on the observation of the context, type and significance of the pain experience. Assessment as well as proper documentation is required for reporting the pain and for improving pain management. The records are to be made on pain history, location of the pain and its intensity so as to understand and report them (“Pain Assessment and Measurement,” n.d.).

Questions 13

The techniques and core skills required by a nurse to obtain information about a client is fundamentally dependent on their communication skills. It helps to acquire maximum information through interaction by creating a positive environment for the patient (“Communication Skills,” 2017). Furthermore, nurses should develop the skills to understand non-verbal communication by the patients using the Face, Legs, Activity, Cry and Consolability (FLACC) Behavioral Pain Assessment Scale. This technique can help the nurses to understand the client’s medical conditions by examining the movements of their face, legs, activity, cry and consolability (“Pain (any cause) Nurse Management Guidelines”, 2018). Subsequently, critical thinking skills are essential to nurses to integrate information, outcomes, evidence, experience and then transform them into an effective plan to resolve the problems faced by the patients (Nursing and Midwifery Board of Australia, n.d.).

Question 14

There are various sensory problems that a client faces and among them, the three problems are Autism spectrum disorder (ASD), deafness and low vision (“Types of sensory disabilities,” 2018). ASD is a health condition, in which a person might have a problem to interact with the others. Hence, specialized and intensive education program can prove to be an effective aid in helping clients (‘Autism spectrum disorder (ASD),” 2018). In order to help the deaf clients, various hearing aids such as behind-the-ear (BTE), in-the-canal (ITC) and completely in the canal (CIC) can be recommended. The others aids entail contra lateral routing of signal (CROS) and spectacle aids, whereas the devices such as alternative listening device (ALD) can be used to help the clients in the long run(Australian Government Department of Health, 2017). Moreover, in order to help low vision people, magnifiers such as electronic video magnifiers and Handheld Illuminated Magnifiers can be used (“Acquired Deafblindness,” 2018).

Question 15

There is a range of tools, which are validated to conduct cognitive screening which can help identify deficits. The tools, which can be used to identify the cognitive deficits, are the screening tools such as Abbreviated Mental Test Score (AMTS), DRS-R-98, Short Portable Mental Status Questionnaire (SPMSQ), Standardized Mini mental state examination (SMMSE) and Rowland Universal Dementia Assessment Scale (RUDAS) (“Cognitive screening tools,” 2018).

Question 16

The deep breathing exercise is used in the healthcare settings, when a person faces difficulties in breathing. This difficulty can occur due to lung diseases such as asthma, chronic bronchitis, emphysema and bronchiectasis. Deep breathing is done in order to strengthen diaphragm while the prolonged out-breathing is done to drive out trapped air in the lungs, thereby making room for fresh air while breathing in. Deep breathing exercises can improve the health conditions of a person suffering from lung diseases and can also maintain the functioning of chest (“Breathing problems and exercise,” 2018). Moreover, coughing exercises can enhance the health conditions during bed rest or after anesthesia along with lung expansion (“Breathing & Coughing Exercises,” 2018).

1. Agency for Clinical Innovation. (2018). Cognitive screening tools. Health Professional. Retrieved from https://www.aci.health.nsw.gov.au/chops/chops-key-principles/undertake-cognitive-screening/cognitive-screening-tools

2. Australian Catholic University. (2018). Breathing & coughing exercises. Australian Catholic University. Retrieved from http://www.acu.edu.au/vhe/store/breathing__and__coughing_exercises

3. Australian Government Department of Health. (2017). Types of hearing devices. Client Information, 1-3.

4. Better Health. (2018). Incontinence – tips for carers. Home. Retrieved from https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/incontinence-tips-for-carers

5. Continence Foundation of Australia. (2018). About continence products and aids. Home. Retrieved from https://www.continence.org.au/pages/continence-products-and-aids.html

6. Emergency Care Institute. (2018). Pain (any cause) Nurse Management Guidelines. Network. Retrieved from https://www.aci.health.nsw.gov.au/networks/eci/clinical/ndec/pain-any-nmg

7. Maya. (2015). Assisting seniors with mobility problems. Home. Retrieved from http://ilsau.com.au/assisting-seniors-with-mobility-problems/

8. National Health and Medical Research Council. (2015). Healthy eating when you’re older. Home. Retrieved from https://www.eatforhealth.gov.au/eating-well/healthy-eating-throughout-all-life/healthy-eating-when-you%E2%80%99re-older

9. Nurse & Midwife Support. (2017). Communication skills. Home. Retrieved from https://www.nmsupport.org.au/students-and-graduates/communication-skills

10. Nursing and Midwifery Board of Australia. (n.d.). National competency standards for the registered nurse. Introduction. 1-11.

11. SA Health. (2016). Dignity in care. Home. Retrieved from http://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs/dignity+in+care

12. Senses Australia. (2018). Low vision aids. Deafblind Information. Retrieved from https://www.deafblindinformation.org.au/acquired-deafblindness/equipment-assistive-devices/low-vision-aids/

13. State of Victoria. (2018). Autism spectrum disorder (ASD). Better Health Channel. Retrieved from https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/autism-spectrum-disorder-asd

14. State of Victoria. (2018). Breathing problems and exercise. Better Heath. Retrieved from https://www.betterhealth.vic.gov.au/health/HealthyLiving/breathing-problems-and-exercise

15. State of Victoria. (2018). Sleep – insomnia. Better Health, 1-2.

16. TAFE NSW. (2017). Personal care: reporting and documenting. TAFE NSW. Retrieved from https://swsi.moodle.tafensw.edu.au/mod/book/view.php?id=417008

17. The Royal Children’s Hospital Melbourne. (n.d.). Dehydration. Clinical Practice Guidelines. Retrieved from https://www.rch.org.au/clinicalguide/guideline_index/Dehydration/

18. The Royal Children’s Hospital Melbourne. (n.d.a). Pain Assessment and Measurement. Health Professionals. Retrieved from https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Pain_Assessment_and_Measurement/

19. Victoria State Government. (2018). Personal hygiene. Home. Retrieved from https://www.education.vic.gov.au/school/principals/spag/health/Pages/personalhygiene.aspx

20. Victoria State Government. (2018a). Maintaining and improving mobility and self-care. Home. Retrieved from https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/older-people/falls-mobility/mobility/mobility-improving

21. Victoria State Government. (n.d.). Dentures. Better Health, 1-3.

22. VRB. (n.d.). Activities of daily living. Introduction, 219-223.

23. Williams, A. M., Lester, L., Bulsara, C., Petterson, A., Bennett, K., Allen, E.,… Joske, D. (2017). Patient Evaluation of Emotional Comfort Experienced (PEECE): Developing and testing a measurement instrument. BMJ. 1-9.

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