Assignment On Nursing Student Institution 2022

Nursing
Student assignment
Institution

Introduction
This report will discuss Alice McCallum's case study. The patient was admitted in the
hospital three days ago after being referred by her GP. She presented with confusion and an
increased risk of falls due to hyponatremia. On assessment during admission, she had a GCS of
14 and generalized weakness on both legs. She also presented with bilateral limb spasm. She was
managed on sodium chloride 0.9%, and the patient showed a marked improvement. However,
her condition worsened about an hour ago, and her GCS is 13, and the patient is confused and
feeling drowsy. The report will, therefore, discuss sepsis (infection) and fluid volume deficit as
the two actual problems presented by the patient. The pathophysiology of these conditions will
be discussed, and appropriate interventions needed to manage these conditions will be presented.
Goals and expected outcomes will also be presented together with how to evaluate.
1. Infection
Infection is caused by the entry of micro-organisms into the body of an individual mainly
due to break or altered body defence mechanisms such as the skin or insertion of foreign bodies
into the body. Most common micro-organisms are the bacteria. They include streptococcus,
staphylococcus, and pneumococcus. Others include viruses, protozoa and parasites such as
trachinalis spiralis (Gast &Porter 2020). These organisms enter the body and start multiplying.
The body recognizes micro-organism as foreign and initiates a response. The infection can be
either local or systemic or both. The body responds to a local infection through inflammation
(Kourtis et al. 2019).
Inflammation is the activation of the immune system due to stimulus usually micro-
organisms. This involves both the cellular and humoral components (Liu et al. 2017).
Inflammation has three phases which are the acute, sub-acute and chronic phases. The acute
phase, which usually lasts for about three days, is characterized by swelling, redness, pain, loss
of function and heat. This is caused by constriction of arterioles at the site of injury initially and
vasodilation and increased capillary permeability later. This is due to the release of chemical
mediators which relax the smooth muscles of arterioles. This leads to the exit of protein-rich
fluid into the interstitial space initiating an inflammatory response. This fluid contains plasma
components such as albumin, fibrinogen and kinins. This, therefore, leads to symptoms of
inflammation which include swelling, redness, pain, loss of function and heat (Ahmed et al.
2017)

During the sub-acute phase, the phagocytic cells move to the site of injury. In response,
leukocytes, platelets and erythrocytes adhere to the endothelial cell surface. Neutrophils are the
first polymorphonuclear leucocytes to reach the site of the infection (Martinez et al. 2016). Then
followed by basophils and eosinophils and finally, the macrophages predominate. The
macrophages remove damaged tissues, and the repair face is followed if the cause of
inflammation is eliminated. If not, then the inflammation moves to chronic phase causing more
tissue destruction (Kikuchi et al. 2018).
Fever is the body’s response to an infection. An infection in the body activates cytokines
to induce an upward displacement of the temperature set point in the body to increase body
temperature. This is mediated with an increase in the synthesis of prostaglandins which act on
the hypothalamus to raise the temperature setpoint (Eldin et al. 2017). It is believed that an
increase in body temperature enhances immune function and inhibits pathogens growth.
Increased infiltration of polymorphonuclear leukocytes increases white blood cell count in the
body. This is because the cells are attempting to eliminate the infection-causing micro-
organisms. The patient shivers as a response to fever. This is because the body tries to generate
more heat.
The first nursing intervention is the administration of an antipyretic to reduce the fever
and also to expose the patient. Paracetamol can be used as an antipyretic agent. This is because
paracetamol inhibits the synthesis of prostaglandins; therefore, a decrease in temperature set
point. It also promotes heat loss through vasodilation of cutaneous blood vessels and sweating
helping to reset the hypothalamic set point. Very high temperatures can damage the brain. The
nurse should monitor for any side effects and toxicities that can arise due to administration of the
drug (Chiumello, Gotti & Vergani 2017).
Another intervention is the administration of antibiotics as prescribed. Broad-spectrum
antibiotics should be administered, but antibiotics sensitive to the organism should be
administered once specificity has been identified. Antibiotics such as Amoxicillin, ceftriaxone,
and ceftazidime. Can be administered to eliminate the organisms (Moon 2019). These drugs
target specific molecules that are present in infection-causing organisms but not in the body
cells. These include cell wall components, certain proteins such as the 30s and other components.
The drugs target these components causing the death of the organisms. Once destroyed, they are
eliminated by the body as waste products. Antibiotics are administered for a certain period of

time, preferable 14 days in order to eliminate the organism fully. The nurse should, therefore,
ensure that the patient receives her medication in the right dosage, route and time as prescribed,
especially when the patient is confused. Drug adherence will help prevent resistance and quick
elimination of the disease-causing micro-organism (Gaal et al. 2016).
The third nursing intervention is practising aseptic technique to prevent further infection.
Sites of intravenous insertion should be dressed using aseptic technique and dressed with a sterile
dressing material. Any other procedure such as intravenous drug administration should also be
carried out using aseptic technique. This will prevent the introduction of micro-organisms to the
patient's body which is already weak (Team, 2019).
The first nursing goal is that the patient shall demonstrate a decrease in temperature to
37.2 at the end of one hour. This is after administration of paracetamol and exposing the patient.
This can be evaluated by taking the patients temperature after every 15 minutes to evaluate if the
temperature is decreasing. If there is no change in temperature or continued increase in
temperature, the intervention should be reviewed or changed to an appropriate one after
identifying the problem (Erickson, 2018).
Another goal is that the patient shall demonstrate a decrease in symptoms of
inflammation at the end of the shift and resolve of the symptoms at the end one week. Antibiotics
acts on the organisms responsible for the infection. Once the organisms are eliminated,
symptoms disappear. Daily evaluation should be taken obtaining both objective and subjective
data to identify any arising complications or improvement. This will enable the nurse to
implement the appropriate intervention as soon as possible to prevent complications and
facilitate quick recovery.
Any signs of new infection should always be observed at the site of intravenous insertion
or any other part.
2. Fluid volume deficit
The second actual problem is fluid volume deficit. The patent has a low blood pressure of
98/60 mmHg, tachycardia HR of 135 beats per minute, increased capillary refill time of 4
seconds and cool extremities (Tigabu et al. 2018). These signs are an indication of reduced fluid
volume in the body. Sodium plays an important role in increasing the amount of body fluid in the
body. Bendroflumethiazide is a diuretic agent and is used to reduce blood pressure by increasing
water loss through urination and inhibits sodium reabsorption.