Medical Surgical Nursing Task 2022

Medical Surgical Nursing
1
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Last name__ _student number_NUR251 S2 2019 Assessment 1

Task 1:
Firstly, assessment will be performed in the form of physical and vital signs
assessment. Physical assessment will be performed through head-to-toe
examination. In case of David, physical and vital signs should be assessed to plan
for the future treatment (Mok, Wang, and Liaw, 2015). Vital signs assessment is
necessary in his case because his all the vital signs such as temperature, respiratory
rate, pulse rate and blood pressure are not within the normal range. Vital signs
assessment is also beneficial in planning future intervention and identify appropriate
referral for further treatment (Mok, Wang, and Liaw, 2015; Lambe, Currey, and
Considine, 2017). Physical and vital signs assessment will be recorded in
observation chart, medication chart and progress notes.
Secondly, fluid balance assessment will be performed for David. Fluid balance
assessment will be performed through assessment of fluid volume, monitoring of
associated complications, monitoring cardia rhythm, assessment of serum levels of
electrolytes and assessment of neurological manifestations. Fluid balance
assessment is the essential in case of David because imbalanced fluid status can
exaggerate acute kidney injury in him (Chuang, 2016; Davies, Leslie, and Morgan,
2017). Assessment of fluid balance is essential in patients with kidney disease
patients because salt and water accumulation can lead to organ dysfunction
(Chuang, 2016). Record for fluid balance will be maintained in charts such as fluid
balance chart, daily weight chart, stool chart, fluid prescription chart and medication
chart.
PQRST algorithm will be used for the pain assessment in case of David. Pain
assessment is necessary for him because early intervention can be planned for him.
Moreover, pain relief can provide physical, psychological and emotional relief for
David. Some patients might deny existence of pain; hence, it is essential to confirm
presence of pain in such patients through pain assessment. Pain assessment is
necessary for David because he is associated with acute kidney injury and pain is
the prominent manifestation of pain (Varndell, Fry, and Elliott, 2017). Pain
assessment will be recorded in observation chart, progress notes and medication
chart.
2
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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
improve well-being in
David.
Assess pain in David using PQRST
formula.
Monitor tachycardia, tachypnoea and
hypertension.
Assist David and facilitate easy
movement of David during re-
positioning.
Encourage, educate and ensure David
is reporting acute pain immediately.
Observe verbal and non-verbal
communication associated with
analgesia requirement, guarding and
moaning.
Pain assessment using PQRST
formula will be useful in planning
early intervention (Duke, Botti, and
Hunter, 2012).
Occurrence of tachycardia,
tachypnoea and hypertension might
occur due to pain sensation (Duke,
Botti, and Hunter, 2012).
Re-positioning assistance will be
helpful to prevent muscle
discomfort, risk of fall and injuries
(Duke, Botti, and Hunter, 2012).
Untreated acute pain can get
aggravated to chronic pain which
would be difficult to treat (Duke,
Botti, and Hunter, 2012).
Majority of the pain associated
communication can be done
through non-verbal communication.
Hence, effective intervention can be
David reported that his pain is 2/10 on
VAS scale.
Vital signs for David remain in the
normal range such a BP 80/120, pulse
rate 60-100, RR 12-20 and temperature
36.2.
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Ensure David is consuming analgesia
on the regularly. Perform timely
assessment and monitoring of efficacy
and adverse effects of analgesic
medicines Administer analgesia on
regular basis with respect to score on
pain scale.
planned (Pham et al., 2017).
Analgesia get rid of pain. Regular
observation of patient is beneficial
in monitoring efficacy and adverse
effects of analgesic medicines
(Pham et al., 2017).
David mentioned pain relief and no
adverse effects analgesic medicines.
Nursing problem: Risk of fluid imbalance
Related to: Urine retention attributable to reduced fluid intake.
Goal of care Nursing interventions Rationale Evaluation
Sustain
normovolaemic
status through
eliminating
hypovolaemic and
hypervolaemic
condition.
Observe fluid intake and urine and
vomit output. Record it on the fluid
balance chart.
Observe, monitor and record signs and
symptoms like tachycardia,
tachypnoea, hypotension, venous
distention, headache, crackles and
level of consciousness.
Hypovolumic or hypervolumic status
can be recorded through recording
weight on regular basis. Moreover,
fluid balance chart gives idea of
these conditions. Observations of
such conditions facilitate either fluid
administration or fluid restriction
(McGloin, 2015).
Observations and monitoring of
signs and symptoms such as
tachycardia, tachypnoea,
hypotension, venous distention,
headache, crackles and level of
consciousness are beneficial in
confirming hypovolaemic and
hypervolaemic condition
(McGloin, 2015).
Hypovolumic or hypervolumic condition
not observed in David.
No signs and symptoms of imbalanced
fluid condition.
4
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