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Identifying two nursing problems specific to 25 year old, Mr Davis

   

Added on  2021-06-14

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Student Name: Emtinan MagyakStudent number: 12464044Subject code: NS2881Subject name: Nursing Practice 3Assessment Title:Integrated Case StudyAssessment Date:29 April2018Campus:TownsvilleSubject Coordinator:Leisa SandersonWord count:
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Introduction:Nurses provide care to all people in many different health care settings with all types of health care needs. This paper identifies two nursing problems specific to 25 year old, Mr Davis, who admitted following a motor vehicle accident. The care plan will be develop, person centred care model will be used to provide care to identified problems. The paper also identifies the interventions with rational and outlines the expected outcome using nursing care plan table. It is guideline for nurses to follow ormaintain the care for the individual patient and is a way of communicating and organising the action or duty of a constantly changing nursing staff. Dehydration and pain management would be the main priories in the situation that the patient is presented with in the orthopaedic unit at the Townsville Hospital.Nursing Care PlanNursing Problem 1Dehydration Nursing GoalsTo Increase Mr David fluid input and output within the next 2hours and within 15minutes check the IV line that is not blocked and delivery the correct amount of dose that required.Interventions with rational Monitor vital signs – decrease urine output, increase respiratory rate, decrease circulation cause patient to become hypotension and confusion (Brown, Edwards, Seaton & Buckley, 2015).Early signs of dehydration – dry lips, dry skin, headache, dizziness and constipation is to prevent kidney failure or heart problem. The kidney helps to control body temperature, decrease blood pressure and increase heart rate(Brown,Edwards, Seaton & Buckley, 2015).Monitor Fluid Balance Chart – not overload the patient with extra fluid input which would cause oedema in extremities limb (Mayo Clinic, 2018).Complication of dehydration – fluid loss that would have impact in kidney functions and electrolyte a balanced (Brown, Edwards, Seaton & Buckley, 2015).Skin turgor – know the skin turgor is mild, moderate or severe that the fluid been lost (skin turgor, 2018). IV therapy – check the correct amount for glucose saline with potassium to provide good means of meeting the routine maintenance needs (National, 2013)Neurovascular assessment – ensure the leg get enough blood flow and oxygen tothe rest of the body, would be looking colour, warmth, movement and capillary refill (Rachael, 2015).Urinalysis – how dehydrated is the patient and check for urine tract infection (Mayo Clinic, 2018).Report and document – informing all the staff member of the action, reason and outcomes (Ossenberg, Henderson& Dalton, 2015).
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Place a sign of nil by mouth – to ensure that all the staff member is aware and notify kitchen staff.Expected health outcomesPatient skin colour return, warm, normal circulation volume, no UTI present, no kidney function problem and vital signs within normal range. Monitor the IV line, report and document the patient process. Normal urine output.Nursing Care PlanNursing Problem 2Managing the painNursing GoalsFree patient for pain and decrease the pain to burley level that patient can tolerance.Interventions with rational Perform a pain assessment – to get good understanding of the pain level, severity, risks of adverse effect, correct nursing action and if the pain radiating in other place of body and redo within 30minutes of admiration of analgise or opioidsdrugs (Tollefson, 2016).The RICE (rest, ice, compression and elevate) technique – reduce the mobility, reduce swelling and reduce future damage or complication (Ossenberg, Henderson & Dalton, 2015).Document vital signs and progress notes – ensure an effective communication is done throughout the team members, report and abnormal vital signs relate to painpatient would be experiencing such as increase heart rate, blood pressure and pulse. Checking medication chart – ensure that medication order meets the patient goalsof reduce the pain, checking for any errors, drug name, dosage and route to reduce adverse side effects(Brown, Edwards, Seaton & Buckley, 2015).Using distraction such as TV, music and Talking to the patient – would help to reduce the stress, anxiety and muscle tension which could make the pain worse. It helps the body to release natural pain relieving chemicals into the brain (university of oxford, 2014).Placing the patient in quiet environment–decrease anxiety, stress and reduce pain (Paula, 2015).Drug therapy – requiring from the doctor increase dose of opioid or an IV (or SC) opioid or IN fentanyl to relieve the pain (Leach, Hofmeyer & Bobridge, 2016).Monitor and report any side effects – knowing the side effects is one of the reasonwhy treatment may failure and non-adherence. This way can be treated early
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