Medical Surgical Nursing Assessment 2022

NUR251 Assessment 1 S2 2019
Assignment template
Task 1
At the commencement of shift, vital sign assessment of patient will be
necessary using the ABCDE (Airway, breathing, circulation, disability and
elimination) checklist to detect any changes in those five areas (Olgers et al.,
2017). The assessment of vital signs using the ABCDE format will help to identify
signs of infection or deteriorating in condition of Mr. David because of chronic
kidney disease. Complete vital sign assessment is necessary to prioritize
immediate nursing interventions for the patient (Thomas, 2018). However, if
the vital sign assessment is not done properly, then it may lead to error in
estimating the effects of treatment on patient and it may lead to delay in
implementing immediate interventions to improve changes in temperature or
breathing.
Secondly, assessment of urine output and fluid management of the patient
will be necessary by the use of a fluid balance chart. This will be done by
monitoring changes in urine output, skin turgor, appearance, symptoms of
oedema, colour and characteristics of urine and review of laboratory data on
eGFR (Bleyer, 2014). In patients with chronic kidney disease, there is
obstruction in urinary flow resulting in diminished GFR and changes in
concentration of urine. Due to loss of kidney function and decrease in GFR,
problem in urinary excretion is seen. Therefore, the assessment of urine output
is vital to manage impaired urinate elimination and prevent further damage to
the kidneys. It will help to track improvement in urinary output of David following
treatment implemented after admission. In addition, strict fluid monitoring and
assessment of fluid intake is vital to ensure that there is no risk of water
retention and problem in emptying of the bladder for patient (Beerendrakumar,
Ramamoorthy & Haridasan, 2018). If this assessment is not done, it may lead to
poor detection of urinary elimination and fluid retention related problem in
patient.
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Thirdly, a pain assessment of David using the PQRST pneumonic will be
important to evaluate relief in pain symptoms and decrease in right flank pain
that the patient was experiencing (Raina, Krishnappa & Gupta, 2018). The
detailed pain assessment will help to gain understanding about current level of
pain, patient’s satisfaction with overall treatment and their comfort level
following the implementation of treatment. The outcome or data from this
assessment will be recorded in patients progress note and shared with the
involved medical team. Hence, this assessment is vital for patient’s comfort and
improvement in care experience. In contrast, ignoring this assessment may
result in increased pain, discomfort and poor experience of care for patient.
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Task 2
Nursing Care Plan: David Smith
Nursing problem: Acute Pain
Related to: Right flank pain caused due to acute kidney injury secondary to pyelonephritis
Goal of care Nursing interventions Rationale Evaluation
To reduce right
flank pain and
reduce discomfort
and emotional
stress for David
due to pain
 Assessment of pain using
the PQRST pneumonic to
collect data on severity of
pain, location, timing and
type of pain
 To look for non-verbal cues
of pain such as facial
grimaces, pallor and change
in appetite
 Administer analgesic as
ordered by the physician
according to the level of
pain or pain score.
 The PQRST method helps
in complete assessment
as it provides important
diagnostic cues to predict
the mechanism of pain
and develop tailor made
intervention for patient
(Hui & Bruera, 2014).
 The estimation of degree
of pain and discomfort for
patient is often
understood by their non-
verbal expression. The
 David expresses his pain
level as 2/10.
 He seems to be tired and a
bit worried. He is restless and
has a flushed appearance
 Evaluation will be done by
reduction in pain score and
decrease in discomfort level
 Relaxed attitude and no
stress can give indication of
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Considering the side effects
and efficacy of medication
after administration is
necessary too (Malamed,
2017).
 Provide non-
pharmacological therapies
for pain relief such as
relaxation techniques,
stretching or change in
position
 Involve multidisciplinary
health care team in
managing pain and
emotional discomfort for
David
 Provide patient education
regarding the cause of pain
and the rationale for
providing pain medication
process can give idea
about David’s experience
of pain (Ruben, van Osch
& Blanch-Hartigan, 2015).
 As pain is the most
common symptom for
patients with advanced
kidney disease, use of
analgesic will help in
good pain control and
reduction in psychological
triggers in patient due to
pain (Davison, 2019).
 Non-pharmacological
management of pain is
favoured because of
relied in emotional
aspects of pain and low
chance of side-effects
due to treatment
(Ambrose & Golightly,
2015).
improvement in emotional
and mental outcomes due to
pain
 David has good overall care
experience
 Reduction in stress related
outcomes
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 Multi-disciplinary
involvement will facilitate
maintaining continuity of
care (Nanapragasam, Lim
& Maskell, 2019)
 Patient education reduces
confusion regarding care
and increase satisfaction
with care (Ingadóttir &
Zoëga, 2017)
Nursing problem: Risk of fluid imbalance
Related to: bilateral pitting oedema to his calves
Goal of care Nursing interventions Rationale Evaluation
To manage fluid
imbalance and
decrease risk of
fluid retention
 Document details about fluid
intake, administration of IV
fluid, urine output and
characteristics of urine using
a fluid balanced chart
 Assess patient for signs of
 The importance of
nursing assessment
related to fluid intake and
documentation of fluid
balance chart is that it
can help to predict fluid
 Currently, Mr. Davis has
urinated 100 ml urine after 4
hours of hospital admission
and he has 2 IVC inserted.
Changes in urine output can
be evaluated
 Fluid imbalance has been
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fluid imbalance by
assessment of skin turgor,
dyspnoea, detecting signs
of fluid retention and level of
thirst
 Restrict fluid intake for
patient and educate patient
about the importance of
controlling fluid intake to
prevent deterioration of
symptoms.
 Palpate ankles and feet of
patient
 Conduct assessment of
respiratory pattern and
auscultation of the lungs
 Reposition patient after
every 2 hours
retention risk in patient
and track deterioration in
kidney function of
patient. It is necessary to
detect abnormalities in
fluid status or risk of fluid
overload (Kooman & van
der Sande, 2019).
 For patients with
electrolyte imbalance,
signs of dyspnoea,
confusion and oedema
are common symptoms
to detect risk of fluid
imbalance. Hence,
assessment and
documentation of fluid
imbalance is critical to
identify changes in fluid
dynamic due to kidney
failure for patient (Balcı
et al., 2013)
found for David evidenced by
symptom of pitting oedema
 Adequate uptake of fluids
and decrease in oedema can
be an indicator of positive
outcome of the intervention
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