NUR250 Assessment 1 S1 2018: Patient Assessment, Care Planning, and Medication Management

NUR250 Assessment 1 S1 2018
Assignment template
It is recommended you do not delete the heading and the information below.
Please note:As indicated in Assessment 1 information, a cover sheet, title and contents
pages are not required
Before you begin take a minute to fill in your details in the footer to ensure your document is
identifiable. To access the footer, double click on the grey writing “Last name….” at the bottom of
the page above. Once you have done that, double click here to come back to this page.
Information about the requiredline spacing and font size and type is in the Assessment 1 information
document in the Assessment 1 folder on NUR250 Learnline. Take a minute to check that this
document meets those requirements.
To avoid or minimise problems with formatting, it is recommended you
 Use the headings provided
 Don’t copy from another document onto this template
 Don’t delete the section breaks on the document
Submission of your assignment means you have read and understood the
 University policies and procedures related to academic integrity
 Assessment 1 presentation guidelines
Start to write your assignment here. Word count is calculated from this point.
Task 1: Patient assessment
For providing safe and effective care to the patient, patient assessment plays a pivotal role in nursing
care. It is the responsibility of the licensed nursing practitioner to record these assessments with
utmost competency in order to help the patient reach utmost health (Kotronoula et al., 2014).
Jim who is a 58 year old homeless male is presented to the emergency department with the
symptoms including dyspnea, myalgia, fatigue, malaise, rhinorrhea and headache and thus, Jim
would be assessed for:
1. Airway
2. Breathing pattern
3. Body temperature
Airway:
1
Double click here to fill in this footer
Lastname__ _student number_NUR250 S1 2018 Assessment 1

 Absence of an effective airway clearance can be observed if the presence of runny nose or
“rhinorrhea” is seen
 It is also presented as alterations in the rate and depth of breathing
 Non productive persistent cough is present with the production of sputum
 An ineffective clearance of airway will lead to dyspnea and restlessness
An early and regular assessment of the airway will help in early nursing interventions making it
possible to achieve and maintain a patent airway for Jim and increasing patient compliance to the
treatment.
Breathing:
 An abnormal breathing pattern is evident with coughing and increased rate
 Presence of erythema and inflammation of the tonsils and pharynx
 Presence of wheezing
Assessing the breathing pattern aids in ruling out reasons which resulted in the deviation from
normal pattern. Recording and periodic checking of auscultation sounds will give a regular update
about the respiratory status and providing the symptomatic interventions required.
Body temperature: An increase in body temperature is noted as a result of infection and
electrolyte imbalances
 Presence of tachycardia and tachypnea
 Skin feels warm and flushed with dryness on the mucous membranes
Periodic temperature evaluation in Jim’s care has to be incorporated to make sure that the
hyperthermia doesn’t become an uncontrollable one and the vital signs are maintained
Jim is presented with all the mentioned signs and symptoms and an inability in keeping a record of it
by regular assessment will lead to failure in providing the proper initial care which will directly
worsen the symptoms, degrading the vital signs and lung condition which can be life threatening
(Brown et al., 2017).
2
Double click here to fill in this footer
Lastname__ _student number_NUR250 S1 2018 Assessment 1

3
Double click here to fill in this footer
Lastname__ _student number_NUR250 S1 2018 Assessment 1

Task 2: Care planning
Nursing Care Plan: Jim
Note: Dot points recommended in care plan. Click and type in each cell, clickenter in a cell to make it longer. Do not remove text from the template.
A reminder that all rationales must be referenced
Nursing problem: Risk of spread of infection
Underlying cause or reason: Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immunocompromised patients in the hospital setting
are at higher risk of contracting disease resulting in adverse events.
Re
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To prevent and control
the spread of
influenzawithin the
healthcare facility and
the community.
 Vaccination protocol against
influenza should be followed
 Patient should be isolated in a
single room
 Vulnerable people like children and
old age people are discouraged
from visiting
 Vaccination improves immunity
to a particular disease. Flu
vaccine helps in formation of
antibodies in about two weeks
after vaccination. The
developed immunity provides a
protection against the virus
(CDC, 2017).
 Regular checks showing marked
reduction in incidence rates of the
influenza in the community.
 Increased participation and
awareness about following a proper
hygiene and infection control
protocol is observed.
4
Double click here to fill in this footer
Lastname__ _student number_NUR250 S1 2018 Assessment 1