Posted: July 26th, 2021

Health Assessment Nursing Care Plan Workbook

In Analysis Job 2 –Half B you is likely to be required to complete an entire healthcare analysis and nursing care plan on data given to you throughout the case study- Mr. Kevin Jones. The case study data is positioned throughout the E-book – Case Analysis Ideas for Analysis Job 2 (B).

Using the information gathered from the case study of Mr. Kevin Jones, you is likely to be anticipated to doc the analysis you could have undertaken. You is likely to be moreover requested to ascertain four (4) priority factors, develop, implement and think about your nursing care plan for Mr. Kevin Jones.  All data is to be recorded on this Nicely being Analysis & Nursing Care Plan Workbook. Your achieved Nicely being Analysis & Nursing Care Plan Workbook is likely to be assessed using the marking info throughout the NURBN2000 Moodle shell. Print a replica of the marking info and maintain it with you whereas writing your Care Plan to be sure to reply the questions appropriately.

Ideas for Nicely being Analysis and Nursing Care plan (Full: 2000 phrases)

  • This analysis is dependent upon faculty college students being accustomed to the nursing course of as you will be required to adjust to the steps outlined on this course of. In case you aren't accustomed to this, evaluation in any helpful nursing textbook – nonetheless, this has been lined in your prior EN teaching.
  • Full the workbook, guaranteeing you could have answered the entire questions
  • School college students will reveal medical dedication making experience in:

The Nursing Course of.

  1. Identification/ assessmentof nursing points (nursing prognosis)
  2. Planning andImplementation of nursing care
  3. Documentationof nursing info.
  4. Evaluationof nursing care


Study this plan for the analysis exercise:

Train-Analysis Job 2: Full 2000 phrases

600 phrase analysis


Nursing Care Plan

three Evaluation/Points

Anticipated outcomes





Referenced 600 phrase analysis determining bodily & psychological nicely being elements e.g. dehydration might finish in nervousness & confusion (Gulanick & Myers, 2012)

Remaining phrase rely utilised within the the rest of doc (1400 phrases)

Your care planning is likely to be primarily based in your analysis info

Develop a Care Plan based mostly totally on info gathered in your analysis (a,b,c). Then, set up three (three) predominant nursing points and provide targets, interventions, rationale and implementation of that care.

Think about (how worthwhile was the take care of each of the three points acknowledged)

Submit Workbook

Grownup Nicely being Analysis – Full: 2000 phrases


  1. School college students are required to debate the bodily and psychological nicely being elements for the analysis(600 phrases). This will must be written & referenced in line with tutorial writing & referencing necessities.
  2. Set up 4 majorissues for Kevin Jones, his social historic previous and provide a summary of your normal analysis of him. Make sure that you make the most of ‘purpose’ language. This is likely to be very similar to what you will write in nursing notes as an admission historic previous.
  3. Using the Nursing prognosis half, select the three (three) nicely being nursing diagnosisthat you assume are a priority for Kevin and embody the proof out of your analysis that helps this.
  4. Now prioritise these three important Nursing problemsto formulate a nursing care plan for Kevin
  5. Develop a nursing care plan with rationale (referenced) and related interventionsthat is likely to be carried out for Kevin.
  6. Full the evaluation sectionsof the care plan - set up methods in which you'll be able to measure success in relation to each of these interventions.

Write your 600 phrase referenced analysis below discussing the bodily and psychological nicely being elements for Kevin. This will must be written in line with tutorial writing & referencing necessities.(NB: your analysis will roll into the following internet web page).


The current study takes into consideration the case historic previous of Kevin Jones who's a 75 12 months earlier man receiving nicely being and help care suppliers. Mr. Kevin was a  widower dwelling alone as a result of the ultimate 13 years. On this respect, the earlier historic previous of the affected individual must be centered upon the place the  affected individual  Mr. Kevin had  suffered from quite a lot of nicely being  factors akin to prostate enlargement, hypertension, alcoholism, despair and nervousness. Not too way back the affected individual had suffered from cerebrovascular accident (CVA) which has resulted in correct side paralysis. Because of this truth, all through strolling or movement the affected individual seems to bend over to 1 side further. Kevin moreover can't converse clearly as his speech usually turns into blurred, which disables him to express himself clearly, which leads to an emotional outburst throughout the affected individual.

Kevin being an neutral man must reside on his private and by no means be dependent upon the help and care suppliers. These results in widespread confrontation of the affected individual with the care and help service suppliers the place the affected individual would not must adjust to the advice of the help carers. The affected individual depicts extreme ranges of rigidity and needs to return residence. A number of of the medical conditions of the affected individual is likely to be described as follows akin to presence of persistent cough with chills and fever. The affected individual   moreover complained of physique ache along with lack of urge for meals.  A number of of the vital indicators of the affected individual have been well-known for designing of an environment friendly medical care. The affected individual depicted a physique temperature of 38.three diploma centigrade which was barely above common. The affected individual recorded a blood pressure of 90/60, a respiratory cost of 24 breaths per min, pulse well-known at 90 and the partial pressure of oxygen well-known at 93%. The chest x-ray of the affected individual revealed that the affected individual had pneumonia   throughout the lower lobe. Kevin moreover suffered from swallowing difficulties, which resulted throughout the affected individual affected by dehydration. The affected individual seems to be affected by dehydration which made his pores and pores and skin turgor and mucous membranes dry (Castellan, Sluga, Spina & Sanson, 2016). The affected individual had decreased urine output and elevated urine focus and has elevated ranges of blood urea stage. Kevin had erratic and exhausting bowels and suffered from occasional urine  incontinence. Furthermore, antibiotics is likely to be used for the remedy of pneumonia throughout the affected individual akin to ceftriaxone and   azithromycin and so forth (Identify et al., 2016).

Because of this truth, relying upon the indications and indicators expressed by the affected individual the bodily and psychological elements of care is likely to be designed for the affected individual.

Primarily based upon the cumulative nicely being conditions of the affected individual, the nursing priorities which is likely to be designed for the affected individual are- restoring the hydration functionality throughout the affected individual and treating of lower lobe pneumonia. As talked about by Doenges, Moorhouse & Murr (2016), a lot much less water consumption has been associated to diminished metabolism and fewer kidney carry out. With a view to look at the dehydration the affected individual should be put in an environment friendly hydration treatment. The electrolyte and fluid stability all through the affected individual is likely to be restored with the help of channel IV treatment. The affected individual Kevin suffered from pneumonia   resulting in coughing throughout the affected individual, which could presumably block the airway resulting in swallowing difficulties.

  1. (a) Set up 4 Key Nicely being Factors/ points for nursing care
  1. – pneumonia 
  1. –dehydration
  1. -- urine incontinence
  1. – despair

Doc Kevin’s social historic previous

Mr. Kevin is a 75 12 months earlier widower man and lives in a rural location and is the daddy of three kids. Two of his youngsters reside open air Victoria and his heart son lives shut by nevertheless can't give ample time to his father owing to his busy schedule. Kevin had been affected by quite a lot of bodily and psychological nicely being factors which has challenged his autonomy over his daily life. 

Summary of normal analysis for Kevin

The priority primarily based care which must be undertaken throughout the shopper is   the administration of the lower lobe pneumonia throughout the affected individual. A number of of the  protocols  which  would possibly   be adopted throughout the affected individual are  putting the  affected individual on oxygen  treatment which could help  in restoring the  partial pressure of  oxygen (Coleman, Levy, Wiggins & Kinley, 2017).  In case the affected individual complained of shortness of breath venturi masks is likely to be outfitted to the affected individual to help the affected individual with the respiratory course of.

Due to the deteriorating the bodily nicely being throughout the affected individual Mr. Kevin, the affected individual an increasing number of suffered from nervousness and despair. The despair made the affected individual endure from emotional bursts at events. The affected individual was uncanny and wished to return residence as he was a farmer by profession and was anxious about his pet flocks and the crops   which have been being nurtured by his son for a while.  The affected individual moreover grew to turn out to be infurious within the path of the help carers who've been accountable for caring for the affected individual. Because of this truth, therapeutic communication approaches and emotional counselling would possibly help in relieving the traumatised state of affairs of the affected individual (Davidson & Everett, 2015)

Determining Nursing Points (Evaluation)

Nursing Evaluation

A nursing prognosis is an announcement that describes the PERSON’S exact or potential response to a nicely being disadvantage that requires nursing care. It is a three half assertion with prognosis, set off and proof.

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, Okay., Stanley, D. (2014).  Kozier & Erb’s Fundamentals of Nursing (3r Australian Ed.). Pearson: NSW, Australia. 2012, Ch. 13 Internet web page 233 -249

Based mostly totally on Analysis info you could have gathered, select the three (three) priority diagnoses that you simply simply actually really feel are basically probably the most relevant for Kevin.

Be sure to embody what proof you could help this.

Primarily based  upon the  affected individual info   three  nursing care priorities  have been designed  for the affected individual which might be –  remedy  of  pneumonia,  dehydration administration throughout the affected individual,  tre

Nicely being Analysis Nursing Care Plan Workbook

atment of urine incontinence.

 (1) Evaluation: on conducting a   chest x-ray, the affected individual was acknowledged of lower lobe pneumonia

Set off: the rationale for the pneumonia is also due to an an infection by micro organism, viruses and completely different pathogens. The an an infection is likely to be trigged due to random publicity to the pathogens or predisposition to practices akin to alcoholism which leads to irritation of the lungs or would possibly essential lung illnesses (Müller, 2015).

Evidenced by:  Respiratory pattern ineffective, risk for enchancment of pneumonia.

(2) Evaluation: the affected individual had dry and flushed pores and pores and skin along with exhausting bowels which indicated dehydration throughout the affected individual

Set off- the affected individual had swallowing difficulties attributed to the cough which made swallowing powerful for the affected individual. Subsequently, the affected individual was consuming a lot much less water  which made the  pores and pores and skin of the affected individual flush along with the affected individual had erratic and  exhausting bowels.

Evidenced by: Fluid amount poor risk for dehydration

(three) Evaluation- the affected individual was acknowledged with urine incontinence 

Set off – the rationale for the urine incontinence was inadequate drainage by the affected individual, as a result of the affected individual was consuming a lot much less water. This was further represented inside the kind of exhausting and erratic stools by the affected individual.

Evidenced by: Urine incontinence risk for helpful impairment throughout the affected individual.

Nursing Care Plan (Berman et al, 2012, Ch. 13 Internet web page 233 -273)


To develop the Nursing Care Plan:

  • Critically analyse, cluster and validate your analysis info for Kevin into the subsequent format:-
  • Embrace three(three) nursing points prognosis with Aims (outcomes), Nursing Interventions, Rationales (causes)
  • Write clear statements that clearly replicate the problem. It is doable you will use your particular person wording.
  • It is doable you will use the nicely being patterns cluster statements below that will help you set up a nursing prognosis, or likelihood is you will use ones that replicate the individual shopper.

Aims or anticipated outcomes

Have a timeframe and are life like outcomes related to the nursing prognosis.


Are the nursing actions wished to achieve the intention?

Rationale (must be referenced)

The reasons for nursing interventions are recorded intimately.

Determines if nursing interventions are environment friendly and targets have been achieved.  

Evaluation consists of:

  • Assortment of knowledge related to outcomes
  • Comparability of this info with predicted outcomes
  • Revision of nursing actions to targets and or outcomes
  • Drawing conclusions about disadvantage standing after which persevering with, modifying or terminating the care plan
  • Documenting modifications in nursing interventions and outcomes


Now proceed to the Nursing Care Plan below and enter your info

Nursing prognosis: 1

(Nursing Draw back)

 Lower lobe pneumonia


Evidenced by

Respiratory pattern ineffective , risk for enchancment of  pneumonia (, 2018)

Goal & timeframe

The affected individual to be equipped with an entire treatment which might help in environment friendly remedy of the lower lobe pneumonia throughout the affected individual. The remedy outcomes are to be obtained inside a month’s time, the place the affected individual is free of the pneumonia.

Nursing Interventions. (actions to deal with the problem)

Write nursing interventions proper right here

 The nursing interventions which  would possibly  be taken to deal with the problem of  pneumonia  inside  the affected individual  Mr. Kevin has been enlisted over proper right here such as-

· Entry the velocity and depth of  respirations and chest actions

· Noting  areas of decreased and absent air motion akin to crackles and wheezes (Pascoal et al., 2015)

· Altering   place of  mattress usually

· Serving to the   affected individual with right respiratory

· Forcing of  warmth liquids to a minimal of 300 ml/day

· Administration of medicines akin to  expectorants and bronchodilators (Beloncle & Mercat, 2018)

Rationale: (causes) – References wished to validate nursing interventions

A wide range of interventions is likely to be steered over proper right here in an effort to current environment friendly remedy for pneumonia to the affected individual. As talked about by Pascoal  et al. (2016), the deep respiratory exercises may assist in mobilizing of the cough throughout the affected individual.  The forcing in of warmth liquids helps in mobilization of the cough. The expectorants help in low cost of the bronchospasm (Beloncle & Mercat, 2018).  The tilting of the top or altering of the mattress positions may assist in airway clearing.

Evaluation of Care (how worthwhile have been the interventions)

The interventions have been further evaluated for his or her cost of success. A number of of the methods akin to make use of of expectorants have been found to be helpful in clearing of the cough from the chest of the affected individual. The infusion of warmth liquid has been seen to efficiently mobilize the cough throughout the affected individual and in the reduction of bronchospasm.  As argued by Coleman, Levy, Wiggins & Kinley (2017), the deep respiratory exercises have been seen to cut back the bronchospams all through the affected individual.

Nursing prognosis: 2

(Nursing Draw back)



Evidenced by

Fluid amount poor risk for dehydration (, 2018).

Goal & timeframe

The hydration all through the affected individual to be restored inside a ten to fifteen days time.

Nursing Interventions (actions to deal with the problem)

Write nursing interventions proper right here

The nursing  interventions for dehydration  can  be enlisted  via a wide range of steps akin to –

· Analysis of  pores and pores and skin turgor  and oral mucous membranes for indicators of  dehydration

· Monitoring BP for  orthostatic modifications

· Analysis of colour and amount  of urine (Miller, 2017)

· Monitoring of  urine  osmomolality (Li, He, Ying & Hahn, 2014)

· Analysis of  alteration in mentation

Rationale: (causes) – References wished to validate nursing interventions

The above nursing interventions help in evaluating the state of affairs of the affected individual. As talked about by Li, He, Ying & Hahn (2014), fluid loss is likely to be measured with the help of postural hypotension. That's further signified by a 20 mm Hg drop in systolic pressure and a 10 mm Hg drop in diastolic pressure. The orthostatic   hypotension adopted by amount depletion moreover results in elevated coronary coronary heart cost

Evaluation of Care (how worthwhile have been the interventions)

A number of of the intervention methods when utilized with Mr. Kevin have been worthwhile in regulating and administration of the indicators of the dehydration throughout the affected individual.  For example. Measuring the Bloor pressure of the affected individual on a three to six hourly basis along with studying the urine focus and gravity helped in analysing the dehydration necessities throughout the affected individual. Furthermore, use of devices akin to Glasscow scale may help in analysis of the psychological consciousness ranges of the affected individual.

Nursing prognosis: three

(Nursing Draw back)

Urine incontinence  


Evidenced by

Urine incontinence  risk for helpful impairment throughout the  affected individual (, 2018).

Goal & timeframe

The affected individual to be relieved of the indicators of urine incontinence inside per week’s time.

Nursing Interventions (actions to deal with the problem)

Write nursing interventions proper right here

A  number of  nursing interventions would possibly d be designed  for remedy of the urine  incontinence   throughout the affected individual such as-

· Taking detailed information of  frequency and severity of  leakage episodes (Wagg et al., 2015)

· Analysis of the  affected individual’s  recognition of the  need to void

· Looking for remedy methods to reverse the underlying set off

Rationale: (causes) – References wished to validate nursing interventions

A wide range of steps or measures must be taken for administration of urine incontinence all through the affected individual. A number of of those have been evaluated   with the respect to the current state of affairs.

As talked about by Gershman  et al. (2015), investigation of the one actual underlying causes may assist in enhancing the restoration cost. For the tactic of which detailed bodily examination of the affected individual should be carried out. Furthermore, analysing the frequency and severity of leakage may assist in designing of an environment friendly remedy plan.

Evaluation of Care (how worthwhile have been the interventions)

A number of of the methods adopted for the urine incontinence administration of the affected individual had been further evaluated over proper right here. For example, reversing the rationale for the an an infection has been seen to cut back the severity of the sickness. Inside the present context, the affected individual had been affected by dehydration which resulted in erratic bowels syndrome throughout the affected individual. This   further   worsened the urine incontinence present throughout the affected individual. Furthermore, ranking obtained via psychometric assessments have been bencificial in estimating the psychological consciousness ranges of the affected individual in responding to helpful continence.

Start your references on the following internet web page



Beloncle, F., & Mercat, A. (2018). Approaches and strategies to steer clear of enchancment or improvement of acute respiratory distress syndrome. Current opinion in important care, 24(1), 10-15. doi: 10.1097/MCC.0000000000000477

Identify, S. M., Pujol, A. G., Chacón, E. J., Martí, L. H., Pérez, G. T., Gómez, V. S., ... & Vaquer, S. A. (2016). Individualised care plan all through extracorporeal membrane oxygenation. A medical 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 affected individual complexity and nursing care requirement in Intensive Care Unit. Journal of superior nursing, 72(6), 1273-1286. Retrieved from:

Coleman, J., Levy, J., Wiggins, S., & Kinley, J. (2017). Using a model new end-of-life care plan in nursing properties. Nursing And Residential Care, 19(1), 38-41. Retrieved from:

Davidson, P., & Everett, B. (2015). Managing approaches to nursing care provide. Transitions in nursing: getting ready for expert observe. Chatswood, New South Wales, Australia: Elsevier Nicely being Sciences, 125-142. Retrieved from:,+P.,+%26+Everett,+B.+(2015).+Managing+approaches+to+nursing+care+provide.+Transitions+in+nursing:+getting ready+for+expert+observe.+Chatswood,+New+South+Wales,

+Australia:+Elsevier+Nicely being+Sciences,+125-142&ots=E3V2XRQcRH&sig=aMWm94TvMhEtFzdvH1nuc-N4b-Eight&redir_esc=y#v=onepage&q&f=false

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing care plans: suggestions for individualizing shopper care all through the life span. FA Davis. Retrieved from:,+M.+E.,+Moorhouse,+M.+F.,+%26+Murr,+A.+C.+(2014).+Nursing+care+plans:+suggestions+for+individualizing+shopper+care+all through+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 have an effect on of continent and incontinent urinary diversion on prolonged?time interval renal carry out after radical cystectomy in victims with preoperative persistent kidney sickness 2 and chronic kidney sickness 3a. Worldwide Journal of Urology, 22(7), 651-656. Retrieved from:

Li, Y., He, R., Ying, X., & Hahn, R. G. (2014). Dehydration, hemodynamics and fluid amount optimization after induction of primary anesthesia. administration, 69(12), 809-816. Retrieved from:

Miller, C. G. (2017). Dehydration in Nursing Residence Residents: A meta-analysis of causes of dehydration, implications, and folks most in peril. Retrieved from:

Müller, F. (2015). Oral hygiene reduces the mortality from aspiration pneumonia in frail elders. Journal of dental evaluation, 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 medical indicators of fast?time interval survival for ineffective respiratory pattern in youngsters with acute respiratory an an infection. Journal of medical 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 aged people: Report from the fifth Worldwide Session on Incontinence. Neurourology and urodynamics, 34(5), 398-406. Retrieved from:

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