Medical Surgical Nursing: Case Study Analysis and Care Plan Development

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This document is a case study analysis and care plan development for a patient with acute kidney injury and pyelonephritis. It discusses the nursing interventions and goals of care for fluid imbalance, anxiety, pain, skin integrity, and infection risk. It also includes insights into healthcare literacy for the patient.

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Running head: MEDICAL SURGICAL NURSING
MEDICAL SURGICAL NURSING
Name of the student
Name of the university
Author note

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1MEDICAL SURGICAL NURSING
Introduction
Need assessment is the process used by the nursing professionals in which they
conduct a systematic process so that they can collect patient information and then provide
them with effective interventions for their wellbeing (Bednarczyk et al., 2017). In this case
study analysis, the scenario of Mr. David Smith (72) would be discussed who has admitted in
the CDU medical ward with complication related to his of Acute Kidney Injury and is
secondary to Pyelonephritis. The patient hails from Darwin and originally a Caucasian male.
The patient has multiple health complications such as chronic kidney disease with baseline
Egfr 40ml/min/1.73m2, obesity, anxiety, hypertension, chronic venous leg ulcer in left leg,
and diabetes. It was also mentioned in the case study that he is an ex-smoker however he
consumes one full bottle of wine every night. He is able to take care of himself and manages
his activities of daily life. The following sections would discuss about the complications, his
health assessment and with the help if recent evidences would help to develop an effective
care plan for the patient.
Task 1
Upon understanding the complete scenario of the patient, I would start my shift with
the commencement of primarily three assessments in which I would conduct his vital sign
assessment, his nutritional and fluid assessment, and his pain assessment. All these aspects
are important for the patient’s health condition as it would help me to get an overview of
patient’s current situation. Within vital sign assessment, I would conduct the four primary
assessments including body temperature, blood pressure, heart rate or pulse rate and
breathing rate. Within this assessment the blood pressure and respiratory rate would be
critical as the patient has a history of diabetes and extensive smoking. As per the research
studies of De Boer et al. (2017), increased blood pressure of hypertension is associated with
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2MEDICAL SURGICAL NURSING
the increased complication of diabetes and hence, this process would be implemented, with
other vital sign assessments.
The second assessment for Mr. David would be assessing his nutritional and fluid
assessment. As per Claure-Del Granado and Mehta (2016), both of these assessment methods
are effective in determining the current health condition and it would be easier for me to
manage his diet and fluid intake. As per Silversides et al. (2017), while suffering from disease
condition related to kidney, the patients should be checked regularly for their creatinine, their
sodium potassium levels, their blood urea nitrogen levels. Hence, these are the assessment
that would be conducted for his fluid input and output (De Boer et al., 2017). Further, it was
also mentioned that the patient was forcing himself for his diabetic diet and hence, it was
important to observe his complete nutritional status, as he might skip his diet to avoid the
diabetic food. Therefore, these would be the diet and fluid assessment for Mr. David.
The third assessment would be his pain assessment as the patient reported a sharp pain
in his right flank region and it is necessary for analysing the pain state and level for Mr.
David so that with analysis of his pain level, he could be provided with interventions to
manage or control it effectively (Seers et al., 2018). If not analysed properly, it could lead to
severe pain and then it would be difficult to manage as providing morphine with multiple co-
morbidities would be critical (Claure-Del Granado & Mehta, 2016). Hence, these assessments
would be conducted while commencement of my shift.
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Running head: MEDICAL SURGICAL NURSING
Task 2
Nursing problem: fluid imbalance related healthcare problem
This could be related to his kidney damage and resulting fluid volume deficit in his body. Further with acute fluid volume deficit the patient may suffer
from critical renal failure (Bednarczyk et al., 2017).
Goal of care Nursing interventions Rationale Evaluation
1. The primary
goal would be to
achieve stable
fluid volume
measurement so
that the patient
could be
protected from
acute renal
As per Sirvent et al. (2015) for such
conditions, it is important to assess
the venous pressure of patient as
with assessment of this critical
aspect, the risk of fluid imbalance
could be easily assessed.
The second intervention would be
documenting the fluid input and
As per De Backer and Vincent
(2018), increase in the central
vein pressure is associated with
the hypertension and dyspnea.
Both these aspects were
observed in case of Mr. David
and hence, these conditions
would be assessed.
The evaluation would be conducted through
the analysis of the data with control (general
range in a healthy male) so that the level of
abnormality could be assessed (Bednarczyk
et al., 2017).

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1MEDICAL SURGICAL NURSING
failure
2. Another goal
would be to
make patient
aware of his
health
complication
and the
importance of
maintaining
proper fluid
balance for his
fast recovery
output for the patient and weighing
his weight on a regular basis De
Backer and Vincent (2018). This
would help to keep a closer look at
the patient’s condition.
The second intervention that has
been used for Mr. David as
Bednarczyk et al. (2017)
mentions that with increased
fluid concentration, the patient
starts gaining weight. Therefore,
if the patient is suffering from
fluid imbalance. He would
suffer from weight gain or
weight loss.
Nursing problem: anxiety related healthcare problem
This is related to the mental complications of the patient that he is facing or would face while going through the interventions. This is a complication as it could
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2MEDICAL SURGICAL NURSING
reduce the effect of applied intervention on the patient and would affect the recovery process (García-Campayo et al., 2015).
Goal of care Nursing interventions Rationale Evaluation
1. The first goal
would be to help
the patient to
reduce his
anxiety and
make him aware
of different
coping skills
that would
reduce his
health
complication.
The first intervention would be
educate the patient about his
anxiety condition and assess his
knowledge about anxiety
(Martinsen et al., 2016).
The patient would be involved in
communication so that he could
share his complications
As per Vogelmeier et al. (2017),
there are multiple aspects that
could lead to anxiety in the
patient condition and hence, it is
important to understand the
aspects that is affecting patients
thought process.
The second intervention has
been implemented in the care
process as García-Campayo et
al. (2015) mentions about the
complications patients suffer
The effectiveness of these interventions
would be assessed through the analysis of
Mr. David’s stability, his ability to focus on
interventions (Pickett et al., 2018).
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3MEDICAL SURGICAL NURSING
2. The second goal
would be to
educate the
patient about his
anxiety and help
him with
developing
confidence so
that he could
implement the
stress relieving
strategies
applied for him
from during their anxiety that
affects their thought process.
Nursing problem: his pain that he mentioned about while admitting in hospital
This is related to the pain that the patient experienced in his right flank at the time of admission

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Goal of care Nursing interventions Rationale Evaluation
1. The only goal
for this nursing
problem would
be to reduce the
pain level and
the anxiety nd
restlessness
faced by the
patient due to
this condition.
The first intervention would be
conduct pain assessment
The patient would be asked for an
abdominal diagnosis for analysing
the reason of pain (Hager et al.,
2018).
A complete pain assessment
helps the nursing professional to
understand the level of pain
faced by the patient and hence
depending upon the data, the
level of intervention applied for
the patient could be identified
(Schoenfeld et al., 2017).
As per Gold et al. (2019) one of
the primary reason for the flank
associated pain is connected
with positioning issues while
After few days, the pain assessment would
be conducted again and then it would be
compared with the previous data so that the
level of pan reduced could be understood
(Chung & Kim, 2018).
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5MEDICAL SURGICAL NURSING
sitting, sleeping or moving.
Therefore application of
repositioning patient with
application of mild medication
would help to reduce the patient
condition.
Nursing problem: nursing problems associated with integrity of skin
This is related to the skin integrity impairment due to which the patient suffer from the risk of skin disease.
Goal of care Nursing interventions Rationale Evaluation
1. The primary
aim would be
reach the level
of capillary fill
within 6
Firstly, the skin assessment of Mr.
David would be conducted.
The patient would also be assessed
for the increased sensitivity or
inflammation (Avşar & Karadağ,
This assessment would help to
focus upon the complications
that the patient may suffer from
while undergoing critical health
condition (Avşar & Karadağ,
The evaluation would be conducted by
analysing the risk of pressure ulcer as the
patient is suffering from the risk of pressure
ulcer as well as reduced quality of skin
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6MEDICAL SURGICAL NURSING
seconds that
demotes that the
patient’s skin
would not be
swelled or red
2018) 2018) (Kottner & Surber, 2016).
Nursing problem: risk of infection due to the insertion of IVC in both of the antecubital fossa veins
This nursing problem is related to the increases risk due to the inserted IVCs in both of the ACF or antecubital fossa veins of the patient. Improper
handling of both of these insertion sites could be the reason of infection (Cox & Thom, 2018).
Goal of care Nursing interventions Rationale Evaluation
1. If infection is
present then that
should be
identified early
The patient would be limited for his
number of visitors
He would be asked to intake a high
Hand hygiene and limited
number of victor would help to
prevent risk of infection (Cox &
The patients infection assessment would be
conducted every seventh day so that the
amount of infection in the patient’s body

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7MEDICAL SURGICAL NURSING
so that the
prevention
could be
achieved
properly.
2. Conducting
infection
assessment for
both virus and
bacteria so that
the level of
hygiene could
be maintained
within the care
facility.
amount of fluid input
The healthcare professionals
involved in the care process would
be asked to maintain a specific level
of hand hygiene (Narendra et al.,
2019)
Thom, 2018) could be evaluated (Lee et al., 2018).
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8MEDICAL SURGICAL NURSING
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Running head: MEDICAL SURGICAL NURSING
Task 3
After completion of the intervention implementation, the patient would be involved in
the healthcare literacy so that the patient could understood his health complications and could
cope up with his complications after his discharge. There are many aspects that David would
be educated about such as the positive influence of his diet on his diabetic condition, impact
of anxiety on his health, harmful effects of his wine related habit in his diabetes as well as
increased risk of cardiac diseases (American Diabetes Association, 2015). The patient would
be educated about the way his wine consumption, avoidance of diabetic food and his poor
water consumption would affect his hypertension, his dyspnoea and his increase in blood
sugar levels (Coventry et al., 2015). Further, he would be educated about the importance of
his weight management as his obesity is affecting both his diabetes and his acute kidney
disorders (Bos-Touwen et al., 2015). Further, he would also be educated about the
complications related to his obesity, and his increased risk of cardiac conditions, and
impaired physical health (American Diabetes Association, 2015). After explaining his
physiological conditions and the effect of these on his health condition, he would be asked to
maintain a record so that he could develop abilities for self-motivation and could maintain
healthy habits under such influence. Besides these other aspects, related to blood glucose
management, self-evaluation and self-management strategies so that upon facing any
complication he can manage such conditions on his own (Coventry et al., 2015). Therefore
these are the aspects that would be educated to the patient prior to discharge.
Task 4
Progress notes
Patient’s name: David Smith
Date of Birth: 26/03/1948
Medical record number: xxxx Date: xx/xx/xxxx
New patient

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1MEDICAL SURGICAL NURSING
David Smith (72) has been admitted to the CDU medical ward and the primary
complication that has been diagnoses is the Acute Kidney Injury in Pyelonephritis. The
patient has several medical history including fever, fatigue and lack in urine output with
sharp pain in the flank region and after that the patient was transferred to the medical ward
for care process
After admission to the CDU ward the patient seemed very unwell with restlessness due to
his right flank pain. His urine appeared dark and was with offensive smell, that he passed 4
hours ago around 100 ml in quantity. He opened his bowel this morning and he has 2
IVC’s inserted to both of his ACFs. He was also on a diabetic diet which he seemed to be
tolerating.
After commencing my shift I conducted three primary assessment for analysing the
patient’s current scenario and then these were the pain assessment, nutritional and fluid
assessment and vital sign assessment. After this for his pain reduction, pain assessment was
conducted and he was repositioned so that the flank related pain could be reduced. Further,
the patient was provided with education so that he could drink much water to reduce the
risk of infection. An effective communication was also conducted with the patient so that
his anxiety and stress could be reduced. To reduce his risk related to pressure ulcers, his
skin was assessed so that the integrity of his skin could be maintained.
During the discharge, the patient was included in an educational session so that the risk of
diabetes, anxiety and hypertension could be conveyed to the patient and he could overcome
the risks effectively.
The follow up would be conducted on xx/xx/xxxx (after 6 months)
And the patient is fit for discharge process
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2MEDICAL SURGICAL NURSING
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