Complete a comprehensive health of Adult Patient or Client

Introduction

As part of your Assessment Task 3 Part B in this course, NURBN2000 Transition to Nursing Studies, you are required to complete a comprehensive health assessment ononeof the following;

• an adult patient you cared for on placement, or
• an adult client that you care for in your work environment, or
• based on information given to you in a case study- Kevin

Using the information gathered, you are expected to document the development, implementation and evaluation of a nursing care plan for a person, chosen above. All information is to be recorded in this booklet using the prepared formats. The completed Health Assessment including nursing care plan and evaluation of that nursing care plan will be assessed using the marking guide in the NURBN2000 Course Descriptor and Moodle shell.

Guidelines for Health Assessment and Nursing Care plan

• This assessment relies on students being familiar with the nursing process as you will be required to follow the steps outlined in this process.
• Complete the Adult Health Assessment, and
• Students will demonstrate clinical decision making skills in:

1. The Nursing Process.
2. Identificationof nursing problems (nursing diagnosis)
3. PlanningandImplementationof nursing care
4. Documentation of nursing data.
5. Evaluationof nursing care

Plan:

Identifying Nursing Problems (Diagnosis)

To develop the Nursing Care Plan:

• Critically analyse, cluster and validate the assessment data 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.

Nursing Diagnosis

A nursing diagnosis is a statement that describes the PERSONS actual or potential response to a health problem that requires nursing care. It is produced by analysis and synthesis of data. It is a three part statement with diagnosis, cause and evidence. (Review Berman et al, 2012, Ch. 13 Page 233 -273)

1. Goals or expected outcomes.
   • Have a time frame and are realistic outcomes related to the nursing diagnosis.
2. Interventions.
   • Are the nursing actions needed to achieve the goal.
3. Rationales.
   • The reasons for nursing interventions recorded in detail.
4. Evaluation.
   • Determines if nursing interventions are effective and goals have been achieved.

Evaluation.

To determine whether or not the nursing interventions have been 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

Nursing Diagnosis

Based on Assessment data you have gathered on your client/patient/case study, select Three (3) diagnoses that are the most appropriate for that person.

1. Nursing diagnosis: 1(Nursing Problem)

• Evidenced by
• Goal & time frame
• Nursing Interventions.
• (actions to address the problem)
• Rationale: (reasons)
• Evaluation of Care (how successful were the interventions)

2. Nursing diagnosis: 2(Nursing Problem)

• Evidenced by
• Goal & time frame
• Nursing Interventions.
• (actions to address the problem)
• Rationale: (reasons)
• Evaluation of Care (how successful were the interventions)

Nursing diagnosis: 3(Nursing Problem)

• Goal & time frame
• Nursing Interventions.
• (actions to address the problem)
• Rationale: (reasons)
• Evaluation of Care (how successful were the interventions)