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CASE STUDY INFO Mr Kevin Jones is a 75 year old gentleman who is under your care. He has been widowed for 13 years and has recently suffered a stroke. He lives alone in a rural location and was a farmer during his working life. Kevin has 3 grown up children, two of whom live outside of Victoria and his middle son lives nearby but leads a busy working and family life. He does not get along too well with his daughter in law. Kevin is fiercely independent and during his hospitalisation has verbalised his wish to return to his home and manage on his own, against the wishes of his family. Finances are limited. He lives in an old farm house which hasn’t seen renovations for 30 years. He has a wood fire and stove and no shower (just a bath). Past history: Prostate Enlargement, Hypertension, Alcoholism, Depression and Anxiety Currently Kevin has right side paralysis due to his CVA (stroke). Kevin does not appear to notice that he leans to one side and forgets where his right hand may be. His speech is slurred and he has trouble saying some words. This causes him some frustration and he has emotional outbursts at times. He has just started to mobilise with a three pronged stick and he is anxious about his balance. Kevin is anxious about returning home and seems to be fretting about his home, land and animals (currently being taken care of by one of his sons). Some days, Kevin barely talks to the staff and will often get agitated and irritable with the nurses, physiotherapists, cleaners etc. He appears to be ruminiating about his past and his wife. Kevin has been complaining of a chronic cough with a small amount of discoloured greenish yellow sputum, fever,flushed skin, chills, loss of appetite, taking little fluids, malaise and body aches over the past few days. Temp 38.3, BP - 90/60, Resp rate - 24/ min, P 90 , O2 sats - 93%. Crackles & wheezes on auscultation, diminished breath sounds. Chest X-Ray revealed (R) lower lobe pnuemonia Kevin also has some swallowing difficulties and some vision problems with neglect. When he does eat, he prefers puree and soft style deserts e.g. custard. He is not drinking much. Kevin appears to have lost weight. His skin turgor is dry, mucous membranes dry, urine specific gravity is 1.025, decreased urinary output, increased urine concentration and he has an elevated blood urea nitrogen. He is finding that he is more likely to dribble following passing urine and sometimes he is incontinent of urine. His bowels are a little erratic and his stool has been hard and dry lately. Lately, this is causing him considerable distress. School of Nursing, Midwifery and Healthcare Faculty of Health Bachelor of Nursing NURBN2000 Transition to Nursing Studies Semester 1, 2018 Assessment 2 Part B Health Assessment & Nursing Care Plan Workbook Student Name: Student Number: CRICOS Provider Number 00103D Introduction In Assessment Task 2 –Part B you are required to complete a comprehensive health 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: 1. The Nursing Process. 2. Identification/ assessment of nursing problems (nursing diagnosis) 3. Planning and Implementation of nursing care 4. Documentation of nursing data. 5. Evaluation of 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 Interventions Rationale Evaluation 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 Outline: 1. 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. 2. Identify 4 major issues 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. 3. Using the Nursing diagnosis section, select the three (3) health nursing diagnosis that you think are a priority for Kevin and include the evidence from your assessment that supports this. 4. Now prioritise these 3 important nursing problems to formulate a nursing care plan for Kevin 5. Develop a nursing care plan with rationale (referenced) and related interventions that could be implemented for Kevin. 6. Complete the evaluation sections of the care plan - identify ways that you could measure success in relation to each of these interventions. 1. 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). 2. (a) Identify 4 Key Health Issues/ problems for nursing care 1. -- 2. -- 3. -- 4. -- (b) Document Kevin’s social history (c) Summary of overall assessment for Kevin 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. (1) Evidenced by: (2) Evidenced by: (3 Evidenced by: 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. Interventions Are the nursing actions needed to achieve the goal? Rationale (must be referenced) The reasons for nursing interventions are recorded in detail. Evaluation 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 Care Plan (Berman et al, 2012, Ch. 14 Page 250 -273 Nursing diagnosis: 1 (Nursing Problem) Evidenced by Goal & time frame Nursing Interventions. (actions to address the problem) Write nursing interventions here Rationale: (reasons) – References needed to validate nursing interventions Evaluation of Care (how successful were the interventions) Nursing diagnosis: 2 (Nursing Problem) Evidenced by Goal & time frame Nursing Interventions (actions to address the problem) Write nursing interventions here Rationale: (reasons) – References needed to validate nursing interventions Evaluation of Care (how successful were the interventions) Nursing diagnosis: 3 (Nursing Problem) Evidenced by Goal & time frame Nursing Interventions (actions to address the problem) Write nursing interventions here Rationale: (reasons) – References needed to validate nursing interventions Evaluation of Care (how successful were the interventions) Start your references on the next page References Assessment Task 2 (Part B): Health Assessment and Nursing Care Plan on Case Study Value: 40% Word Count: 2000 words Marking Guide (Rubric): See Moodle References: Must be in APA style referencing (see APA Guide / Library) Agree to Plagiarism Statement: Submission: via Moodle drop box Question: You are required to complete a comprehensive health 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). Purpose: This assessment task also aims to extend your knowledge and skills learnt in recognition of prior learning Outcome: To demonstrate your developing skills required to produce a comprehensive nursing health assessment by the