Medical Surgical Nursing Task 2022

Medical Surgical Nursing
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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.
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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.
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Educate David to consume sufficient
fluid and ensure he is maintaining
required fluid balance.
Weight, monitor and record daily body
weight of David.
Assess and monitor skin turgor and
mucous membranes.
Consumption of adequate fluid can
be helpful in avoiding risk of fluid
deficit (McGloin, 2015).
Abrupt change in body weight is the
prominent indication of fluid
imbalance (Pinnington, Ingleby,
Hanumapura, and Waring, 2016).
Altered skin turgor
and dry mucous membranes
prominent indications of dehydration
(Pinnington, Ingleby, Hanumapura,
and Waring, 2016).
No alteration in David’s weight.
Assessment do not demonstrated
dehydration.
Nursing problem: Risk of infection
Related to: Pyelonephritis
Goal of care Nursing interventions Rationale Evaluation
David is not infected. Culture and assess blood sample.
Analyse blood for WBC count.
Culturing and identification of
microorganisms is beneficial in the
early administration of infection
prevention intervention (Bursle et
al., 2015).
Increase in the WBC count is the
prominent indicator of the detection
of infection (Bursle et al., 2015).
Microorganisms are not identified in the
blood samples of David.
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Educate David about the hygienic
condition and educate him about the
use of antiseptic solution.
On consultation with physician,
administer appropriate antibiotic to
David.
Use of antiseptic solution is
beneficial in destroying
microorganisms (Fasugba, Koerner,
Mitchell, and Gardner, 2017).
Antibiotic use in the earlier stage is
beneficial in controlling infection
(Fasugba, Koerner, Mitchell, and
Gardner, 2017).
Nursing problem: Anxiety
Related to: Pain and disability
Goal of care Nursing interventions Rationale Evaluation
Minimize risk of
anxiety in David.
Perform assessment of mental health
status of David through observing,
monitoring communications, gait,
posture and speech of David.
Educate and advise David to follow
relaxation techniques like slow
breathing and muscle relaxation.
Ensure David is following and
comfortable with these techniques.
Educate David about the importance of
anti-anxiety medicines and administer
these medicines to David with
appropriate dose and frequency with
respect to degree of anxiety.
Mental health assessment is
essential for psychological issues
and providing relevant
pharmacological and non-
pharmacological interventions
(Gulanick and Myers, 2016).
Relaxation techniques alters
physiological processes to reduce
RR and BP which helps in reducing
stress and anxiety and enlightening
mood (Gulanick and Myers, 2016).
Consumption of anti-anxiety
medications is beneficial in
augmenting serotonin levels in brain
which can improve mood. Regular
consumption anti-anxiety
medications is essential to achieve
No signs and symptoms of anxiety
observed in David.
David appeared less anxious after
following relaxation techniques
Degree of anxiety reduced in David.
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Assess David’s discharge status which
comprises of living status and support
from family and friends. Counsel David
to minimize mental health issues.
desired effect (Gulanick and Myers,
2016).
Counselling can effectively minimize
consequences of mental health
issue (Gulanick and Myers, 2016).
David’s daughter residing nearby to him
and she aid support him on certain
occasions.
Nursing problem: Impaired skin integrity
Related to: Hyperthermia and altered fluid status.
Goal of care Nursing interventions Rationale Evaluation
Skin remains intact. Assess, monitor and record skin color,
tugor and sensitivity.
Educate, and demonstrate that David is
following ideal hygienic practices.
Moreover, ensure that David is
following practices such as cleaning
body surface with disinfectants pat
drying.
Advise and ensure that David is
wearing fry and clean clothes.
Assessment would be helpful for
planning early intervention
(Murphree, 2017).
In comparison to the moist skin,
clean and dry skin can be
considered as barrier for skin
infection. It is advisable that patting
should be used instead of rubbing
for drying skin because rubbing can
produce trauma to fragile skin
(Kottner and Surber, 2016).
Probability of skin infection can be
effectively reduced by wearing
clean and dry clothes (Kottner and
Surber, 2016).
Skin remains intact.
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Task 3
Discharge planning of David should monitor of infection and acute pain. These two
topics should be included in the discharge planning of David because regular
monitoring of these two aspects would be helpful in lessening his sufferings.
Nurse should educate David about the signs and symptoms of infection. David
should inform Nurse, if he is experiencing with fever and pain because these are the
prominent symptoms of infection. Advice David to inform nurse about the progress of
his condition after the administration of antibiotics. If there is no improvement in the
fever and pain after 2-3 days of administration of antibiotics; David should inform
about it to the nurse. Hence, nurse can inform physician and physician can take
decision to switch to another antibiotic. Moreover, nurse should advise him to drink
excess amount water per day. Hence, it would helpful in flushing microorganisms
with excess urination (Ward, 2011).
David should also be educated about the pain related to AKI. Nurse should inform
him that painful condition is merely due AKI and it is not another disease condition. It
is advisable to inform him that pain mainly occur due to urinary distension and
increased pressure within the renal tract. It should be brought to his notice that pain
in AKI can radiate to the lower back. Hence, he should be focused on minimising
pain in the urinary tract instead of worrying about the lower back pain. David should
be informed that pain in AKI is steady and dull and it mainly localised towards outer
abdomen of flank region. Increase awareness of David about the pain related
aspects such as timing, quality, location, duration and intensity and advise him to
inform these pain related aspects to nurse. It would be helpful for the nurse to take
necessary actions for planning required intervention for pain management (Bryant,
Knights, Darroch, and Rowland, 2018). David should be advised to consume
adequate amount of fluid unless contraindicated because it would be helpful to dilute
urine and reduce irritation in the bladder which can reduce pain in the urinary
bladder. On daily basis, David should be advised to use warm baths, warm packs or
heating pads during episodes of high intensity pain (Bellomo, Vaara, and Kellum,
2017; Bryant, Knights, Darroch, and Rowland, 2018).
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Task 4
Clinical pathway followed for providing care to the David. In the initial hours physical
and vital signs assessment was performed and based on the observations specific
interventions were planned. In the initial assessment all the vital sign parameters
remained above normal. His observed vital signs were BP (160/95 mmHg), RR (22)
and HR (96 bpm). His physical condition is not normal. He is associated with
disability and pain and also, he reported tiredness. It is evident that he is not alert to
time and place because he anxious and worried. He looks restless and unwell due
overall health detoriaation with respect to physical, physiological and psychological
abnormalities. Today morning, he opened his bowel and his measured urine output is
100 ml since last four hours. It indicates his urine output is low with dark colored
urine with aggressive smell. He is eating diabetic diet and he is comfortable with this
diet. There is no problem in his mobility which is evident from his independent
mobilisation and completion of ADL’s with ease. His skin is intact which is evident
from no indications of infection and dehydration.
His pain intensity reduced after the administration of pain medications such as
paracetamol 1 g QID and morphine 2.5 mg. His observed pain score was 2/10.
However, there is no reduction in BP after administration of BP because even after
administration of Ramipril 10 mg OD; his BP remains at higher level. Moreover, his
body temperature (38.4̊C) measured at above normal level after consumption of
paracetamol 1 g QID. All the medications administered apec. Infection is evident from
the WBC count (1.5 X 109/L). Education provided to David. Discharge of David is
permitted by the doctor and advised to revisit after two weeks for F/U. D/C paperwork
completed. Advised to monitor infection symptoms and pain on the daily basis and
instructed to contact nurse in case of observed symptoms.
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Key (if required)
AKI – Acute kidney injury
BP – Blood pressure
RR – Respiratory rate
HR – Heart rate
D/C discharge
F/U follow-up
ADL’s activities of daily living
PQRST provocation/palliation, quality/quantity, region/radiation, severity
scale, timing
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References:
Bellomo, R., Vaara, S.T., and Kellum, J.A. (2017). How to improve the care of
patients with acute kidney injury. Intensive Care Medicine, 43(6), 27-729.
Bryant, B., Knights, K., Darroch, S., and Rowland, A. (2018). Pharmacology for
Health Professionals (5th ed.). Australia: Elsevier. Australia.
Bursle, E.C., Dyer, J., Looke, D.F., McDougall, D.A., Paterson, D.L., and Playford,
E.G. (2015). Risk factors for urinary catheter associated bloodstream infection.
Journal of Infection, 70(6), 585-91.
Chuang, C.L. (2016). Fluid Management in Acute Kidney Injury. Contributions to
Nephrology, 187, 84-93.
Davies, H., Leslie, G.D., and Morgan, D. (2017). A retrospective review of fluid
balance control in CRRT. Australian Critical Care, 30(6), 314-319.
Duke, M., Botti, M., and Hunter, S. (2012). Effectiveness of pain management in
hospital in the home programs. Clinical Journal of Pain, 28(3), 187-94.
Fasugba, O., Koerner, J., Mitchell, B.G., and Gardner, A. (2017). Systematic review
and meta-analysis of the effectiveness of antiseptic agents for meatal cleaning
in the prevention of catheter-associated urinary tract infections. Journal of
Hospital Infection, 95(3), 233-242.
Gulanick, M., and Myers, J.L. (2016). Nursing Care Plans - E-Book: Nursing
Diagnosis and Intervention. Elsevier Health Sciences. New York. United
States.
Kottner, J., and Surber, C. (2016). Skin care in nursing: A critical discussion of
nursing practice and research. International Journal of Nursing Studies, 61,
20-8.
Lambe, K., Currey, J., and Considine, J. (2017). Emergency nurses' decisions
regarding frequency and nature of vital sign assessment. Journal of Clinical
Nursing, 26(13-14), 1949-1959.
McGloin, S. (2015). The ins and outs of fluid balance in the acutely ill patient. British
Journal of Nursing, 24(1), 14-8.
Mok, W.Q., Wang, W., and Liaw, S.Y. (2015). Vital signs monitoring to detect patient
deterioration: An integrative literature review. International Journal of Nursing
Practice, 21(2), 91-8.
Murphree, R.W. (2017). Impairments in Skin Integrity. Nursing Clinics of North
America, 52(3), 405-417.
Pham, P.C., Khaing, K., Sievers, T.M., Pham, P.M., Miller, J.M., …Pham, P.T.
(2017). 2017 update on pain management in patients with chronic kidney
disease. Clinical Kidney Journal, 10(5), 688-697.
Pinnington, S., Ingleby, S., Hanumapura, P., and Waring, D. (2016). Assessing and
documenting fluid balance. Nursing Standard, 31(15), 46-54.
Varndell, W., Fry, M., and Elliott, D. (2017). A systematic review of observational pain
assessment instruments for use with nonverbal intubated critically ill adult
patients in the emergency department: an assessment of their suitability and
psychometric properties. Journal of Clinical Nursing, 26(1-2), 7-32.
Ward, D.J. (2011). The role of education in the prevention and control of infection: a
review of the literature. Nurse Education Today, 31(1), 9-17.
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