You are a registered nurse employed by a residential aged care facility to undertake comprehensive nursing assessments, develop plans of care and monitor the implementation and evaluation of this care in the facility. Mr Morrell Bonnici is 68 years of age and was admitted to the aged care facility two days ago.
Mr Bonnici speaks little English. He refuses to take his medications and is spending a lot of time lying on his bed. When approached by a staff member he speaks rapidly and loudly. Mr Bonnici has a reddened area at the base of his spine and his right elbow. He is overweight, has mild right sided weakness from a stroke (Cerebral Vascular Accident – CVA) mobilises independently with a frame and has a history of severe right sided shoulder pain. He has had no bowel actions since entering the facility.
Use the prompt to prepare a nursing care plan with 3 pertinent nursing diagnoses List the nursing diagnoses in order of priority (1 being the highest priority) Document the patient findings using the nursing process on the care plan:
Assessment: Subject and Objective assessment data from the prompt Diagnosis:
minimum 3 nursing diagnosis Planning:
Expected outcomes Interventions: Nursing actions that would be taken for each nursing diagnosis Evaluation:
Met/unmet or partially met Use the provided care plan template (use of an unapproved template with receive an automatic zero) Provide the rationale for choosing the interventions listed in the care plan Pay attention to detail and make sure that the interventions are directly related to your nursing diagnosis Provide options for all possible outcomes: Met, unmet and partially met.