The Medical Surgical Nursing

Medical Surgical Nursing
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Task 1:
Firstly, physical and vital signs assessment will be carried out in case of David.
Different procedures will be followed for carrying out physical assessment which
include observation, auscultation, percussion and palpation. Identification of the
signs and symptoms of the current medical condition can be achieved through the
integrated physical and vital signs assessment (Lambe, Currey, and Considine,
2017; Gabayan et al., 2017). From the case study, it is evident that values of vital
sings in David are outside the normal range. Hence, vital signs assessment is
necessary to assess the extent of normalisation of vital signs. If physical and vital
signs assessment would not have been carried out in David, it would have been
difficult to implement relevant intervention to normalise the values of vital signs
(Gabayan et al., 2017). Different charts will be used for recording physical and vital
signs data and these include observation chart, progress notes and medication
chart.
Secondly, acute pain related to acute kidney injury (AKI) will be assessed in David.
PQRST algorithm will be implemented for the assessment of acute pain. Pain
assessment is necessary in him because it is the one of the most significant
symptoms of AKI. Patients usually are not willing to express their pain sensation. Aa
a result, relevant intervention might not be provided for the management of pain in
AKI patients. Pain assessment is essential in David because it can produce varied
physical and mental conditions; if it remain untreated (Varndell, Fry, and Elliott, 2017;
Coluzzi, 2018). Different records will be used for the updating information related to
pain assessment and these records include observation chart, progress notes and
medication chart.
Thirdly, fluid balance assessment will be carried out in case of David. Different
parameters such as fluid volume, neurological manifestations and cardiac rhythm will
be monitored for fluid balance assessment (Davies, Leslie, and Morgan, 2017). AKI
is usually associated with fluid balance; hence, it is necessary to carry out fluid
balance assessment in case of David. There are chances of accumulation of water
and salt; if fluid balance assessment would not have been carried out in David
(Davies, Leslie, and Morgan, 2017; Prowle, Kirwan, and Bellomo, 2014). Different
charts will be used for recording fluid balance assessment data which include the
fluid balance chart, daily weight chart, stool chart, fluid prescription chart and
medication chart.
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Task 2
Nursing Care Plan: David Smith
Nursing problem: Acute Pain
Related to: Acute kidney injury
Goal of care Nursing interventions Rationale Evaluation
Reduce pain
sensation and
minimise pain rating
on pain scale.
Apply PQRST algorithm to record pain
rating.
Observe, monitor and interpret non-
verbal communication.
Encourage David to report pain
instantaneously. Acknowledge the pain
reports.
Information about pain rating on the
pain scale is beneficial in planning
relevant intervention (Pham et al.,
2017).
Most of the patients do not verbalise
pain; hence, non-verbal
communications can provide clue
about the pain. Hence,
subsequently relevant
communication can be provided to
the patient (Pham et al., 2017).
Persistent pain can produce
psychological problems such as
depression and anxiety; hence it is
necessary to report it immediately.
Moreover, instantaneous pain
reporting by patient and immediate
response form the nurse can build
positive therapeutic relationship
between the nurse and the patient
(Duke, Botti, and Hunter, 2012).
Observed pain score is 2/10 on pain
scale.
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