Medical Surgical Nursing: Case Study Analysis and Care Plan Development

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

MEDICAL SURGICAL NURSING1
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

MEDICAL SURGICAL NURSING2
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.

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).