NUR250 Assessment 1 S1 2018 Assignment Template

This assignment template for NUR250 Assessment 1 S1 2018 covers patient assessment, care planning, medication management and patient teaching. It includes details on lifestyle modifications for hypertension prevention and management, medication management for influenza and pain relief, and vaccination for influenza prevention. The content is relevant for nursing students and covers important nursing concepts.

NUR250 Assessment 1 S1 2018
Assignment template
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Task 1: Patient assessment
An assessment provides an opportunity for nurses to set up a firm and desired therapeutic effect.
Assessment involves multiple steps with the objectives being to diagnose which later become the
basis for nursing treatment. The three most important steps in assessment that would be conducted
to Jim in the day of admission include, comprehensive assessment, quick priority assessment and
lastly focused assessment (Rajinikanth, 2012).
Comprehensive assessment comprised of a detailed assessment on the client. The relevance of
admission assessment is to establish a complete data base, find a base line information and problem
identification. Treatment plan to follow. Obtaining all this information helps in narrowing the
problem of the client. In accurate observation of the client may lead to his death, example Jim has a
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blood pressure of 158/86 mmHg indicating that he was hypertensive and needed immediate care or
else it might resulted to a heart attack.
Quick priority assessment is done at the start of each shift or whenever the condition of the patient
changes at any time. The relevance of this assessment is to identify the life threatening problems
example in rapid assessment of the airway. The information gotten is used in the development of a
care plan. In accurate assessment for Jim may result to serious complication for example Jim has
dyspnea if this problem is not identified early it may lead to suffocation due to lack of adequate
oxygen.
Focused assessment is a detailed nursing assessment which deals body systems. The relevance of
this assessment is to determine the status of a specific problem identified in the earlier assessment,
expose the problem and treat it, the major aim of this assessment is to diagnose and treat the
patient so as to stabilize the condition. Lack of proper focused assessment may lead to not finding
the root cause of the client’s problem hence no diagnosis and treatment would be established
(Bennett, 2013).
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Task 2: Care planning
Nursing Care Plan: Jim
Note: Dot points recommended in care plan. Click and type in each cell, click enter 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.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To prevent and control
the spread of influenza
within the healthcare
facility and the
community.
 Provide patient to patient infection
spread.
 Provide isolation according to
CDC
 Ensure patient with airborne
infection remain in private
rooms during the stay.
Patients contaminated with
airborne diseases should be
contained in one room. If they
have to leave their rooms,
proper procedures should be
 Viruses that are
transmitted through air
are likely to spread and
infect others through
direct contact and can be
spread easily in hospital
(Garner, 2011).
-.strategies developed by
CDC are made to reduce
the possibility of spread
from one patient to
another.
 Transmission from one patient
to another is not evident.
 Health care worker are not
infected
 The nurses and health care
workers are not infected by the
occupational acquired infection.
 There are no signs of
transmission because of the
contaminated equipment.
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followed to prevent the
possibility of contact with
other patients. According to
CDC all rooms should be
ventilated.
 Prevent health care worker’s transfer
of organisms from one patient to
another
- Hand hygiene should be thoroughly
done by either washing hands with
clean water or using of alcohol. Hands
should be disinfected before and after
attending to each patient and after
any procedure.
- Gloves should be used when
attending to patient with body fluids
and should be changed after every
procedure and hands washed when
done with procedures
fluid from any patient.
-long nails should be avoided in the
clinical, nails should be short and clean
- Airborne diseases are
prevented efficiently by
the engineering controls.
-vaccines function by
reducing the risk of
infection involved by the
frequently virulent
condition which is highly
(Rosenstein & Perkins,
2010).
 The common route of transfer of
microorganism by the health care
workers is through the hands
(Shay & Freifield, 2013).
- Inorder to reduce viral infection
hand hygiene is very important.
Alcohol-based hand disinfectants
are effective methods to reduce
transmission (Zaragoza, Salles,
Gomez, & Trilla, 2012).
-Gloves provide effective barrier
protection but it can be one of the
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- Vaccination should be administered
and encouraged In any hospital setting
where patients may have increased
risk for infection.
vehicle to the transfer of
microorganism from patient to
another if used in the wrong way.
(Shlaes, Gerding, John, &
Bronstein, 2014).
Nursing problem: Self-care deficit
Underlying cause or reason: self-care deficit related to fatigue secondary to increased work of breathing and insufficient ventilation oxygenation
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Independence in self-care
activities
 Instruct the client on the methods of
performing a diaphragmatic activity
 Patient should advice to bathe self,
dress self. Discuss energy conservation
measures
 This enhances patient to avoid
excessive fatigue so as to be more
active (Boushey, Fick, Lazarus, &
Martin, 2012)
 As problem settles, the client will
be able to do more but should be
advised on too much dependence.
 The patient performs regulated
breathing during bathing walking band
bending.
 Reduced fatigue and dyspnea with rest
periods during daily activities.
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: risk of imbalanced fluid volume related to myalgia
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Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Maintenance of
adequate fluid volume
 Monitor and record hourly intake and
output
Fluid management may be altered due to
pain in the muscles i.e. mastication
muscles
 Patient is adequately hydrated as
evidenced by urine output greater than
30ml/h
Nursing problem: difficulty in breathing
Underlying cause or reason: impaired gaseous exchange related to ventilation perfusion inequality
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Improvement in gas
exchange
 Administration of bronchodilators
 Instruct and encourage the patient in
diaphragmatic breathing and effective
coughing.
 Evaluate current smoking status,
educate
regarding smoking cessation, and
facilitate efforts to quit.
- Smoking habits of the patient should
be evaluated.
-Educate on the effects of smoking
 Bronchodilators function by
dilating the airways. The
medication dose is carefully
corrected to the desirable result
for each client in a manner
conforming with clinical response
(Pohl, 2011).
 These techniques improve
ventilation by opening airways of
sputum. Gas exchange is improved
and fatigue minimised (McAlister,
 Verbalises the need for bronchodilators
and for taking as prescribed
 Demonstrates diaphragmatic breathing
and coughing
 Identifies the hazards of cigarette
smoking
 Joins smoking cessation classes
 Reports a success in smoking cessation
 Identifies materials for smoking
cessation
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and its relationship to COPD.
- Evaluate the attempts of smoking
after cessation.
- Education materials should be
provided.
Levine, Zarnke, & Campbell, 2012)
 Smoking results to permanent
damage to the lung and decreases
the protective mechanism of the
lungs
 There is obstruction of the airflow
causing an increase in secretion
hence leading to a decreased lung
capacity (Moser, 2014).
 Verbalizes types forms of inhaled toxins
 Minimizes or completely remove
exposures
Nursing problem: generalised weakness
Underlying cause or reason: activity intolerance related to fatigue, hypoxemia and ineffective breathing patterns
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Improvement of activity
intolerance
 Support the patient in establishing a
regular regimen of exercise using
treadmill and exercycle, walking or
other appropriate exercise such as
mall walking
 Muscles are deconditioned to use
more oxygen causing a heavy load
add on the lungs (Truesdell, 2014).
These muscles become
conditioned through regular,
graded exercise making the
patient to do more without getting
dyspnea. Graded exercise breaks
 Performs activities with less shortness
of breath
 The patient shows intrest of exercising
daily by formulating an exercise plan.
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the cycle of debilitation (Knebel,
Bentz, & Barness, 2013).
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Task 3: Medication management
Oseltamavir 75mg orally bd is used in the treatment of symptoms caused by influenza virus.
It relieves and makes less severe symptoms such as fatigue, fever, aches and stuffy nose.
This interferes with the release of progeny influenza virus from infected host cell, thus
halting spread of infection within the respiratory tract (Hirsch, 2013). The nurse should
ensure that the client takes the drug daily for five days. The drug should be taken orally and
should be taken with food to enhance tolerability. Most of the side effects of this drug don’t
really need medical attention. Common side effects of Oseltamivir include nausea and
vomiting.
Paracetamol 4/25 orally pm is used in the treatment of mild to moderate pain example
headaches, pain in the muscles, lowering of high temperatures such as fever and lastly
relieving fever and malaise caused by colds and flu (Olson, 2011). The nurse should ensure
that the patient takes the recommended dosage of the tablets per day, over dosage of the
drug may cause toxicity hence liver damage. Before administration the nurse should ensure
that the client is not allergic to the chemical components of the drug and he also no liver
problem. The drug usually has no side effects, in case of any allergic reactions examples
rashes or swelling the treatment therapy should be stopped.
Fluvax IM stat dose is used in the prevention of influenza (Levinson, 2012). It contains
inactivated form of the influenza virus which cannot cause infection hence making the body
to develop antibodies which act as a defence from getting flu. The nurse should ensure the
vaccine is vaccinated once a year and documented in a card indicating the next vaccine. The
drug is injected in a muscle mostly the upper arm that is the deltoid muscle. The nurse
should take care of not injecting a vein. The side effects of the drug include allergic reactions
which occur rarely and resolve without treatment.
Task 4: Patient teaching
Lifestyle modification for hypertension prevention and management include, lose weight if
overweight, limit alcohol intake, increase aerobic physical activity 30-45 minutes a day,
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sodium should be taken in low quantities, recommended intake of potassium in the diet,
recommended intake calcium in the diet and magnesium for a healthy body and lastly
decrease fatty foods and cessation of smoking for a general cardiovascular health.
The importance of this topic should be understood by Jims so as to familiarise the disease is
caused and how lifestyle modification and medication can regulate hypertension. The
client’s needs to know hypertension can be controlled rather than be cured. The client
should know why tobacco should be avoided not because is connected to hypertension but
because it can cause a heart disease for anyone with high blood pressure.
The only assurance method that will be used so as Jim will understand why it is important, is
by taking him all around the hospital showing him patients who have the problems that he
might have if he doesn’t consider the advice given. In order to prevent the future outcomes
Jim should stop smoking.
Task 5: Clinical judgement and handover
Jim has on a medication for influenza and he was recovering but judging from the presenting vital
signs, high temperatures of 39.6c, a rapid heartbeat of 125beats/min and a high respiration rate of
24 breaths per minute and a low oxygen saturation on room air, Jim has developed withdrawal
syndromes this is evidenced by the history taken which indicated that he smokes cigarettes five to
ten time a day. On the two days that he has been in the hospital he has not been smoking cigarettes
hence the withdrawal symptoms. The following drugs can be used to decrease the amount of
nicotine in the body, they include over the counter nicotine replacement medications such as the
skin patches and the nicotine gum and second is the nicotine prescription replacement methods
such as the inhalers and nasal spray.
MR Jim a 58 year old indigenous male was presented to the emergency department with
dyspnea, myalgia, fatigue, malaise, rhinorrhoea and headache. On examination he was found out to
have clear nasal discharge. His medical history indicated that he had asymptomatic hypertension,
allergic to chicken and an active smoker. On physical assessment the skin was hot and diaphoretic.
He had musculoskeletal joint disorder, bilateral wheezes and undernourished. Vital signs check-up
showed he had high temperatures, heart rate and blood pressure. The patient was diagnosed with
influenza and was administered Oseltamivir as a starting dose. Other medication administered were
paracetamol and fluvavax. Day three post his admission Jim had tested positive for influenza A and
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the influenza symptoms had decreased over the past 24-48 hours. Jim was scheduled for discharge
only after this morning he started complaining of feeling cold. He had high temperatures of 39.6c, a
heart rate of 125 beats per minute, respiratory rate of 24, blood pressure of 124/79 mmHg and
indication of withdrawal symptoms. Close monitoring is required to assess his progress. He has been
reviewed by the doctors and advised to continue with management and rest.
References
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Bennett, C. (2013). Portfolios in the nursing profession – use in assessment and
professionalportfolios in the nursing Profession – use in assessment and professional.
Nursing Standard, 23(6), 30-30.
Boushey, H., Fick, R., Lazarus, B., & Martin, A. (2012). anti-ige: a unique approach to asthma
management. Gardiner- Caidwell syner med NJ, 2, 24.
Garner, J. (2011). hospital infection control practises advisory committee: guidelines for isolation
precaution in hospitals. infection control and hospital epideomiology, 17, 53-80.
Hirsch, M. (2013). medical management of influenza infection. Annu rev med, 59, 397.
Knebel, A., Bentz, E., & Barness, P. (2013). Dyspnea management in alpha-1 antitrypsin
deficiency: Effect of oxygen administration. nursing research, 49(6), 333-338.
Levinson, W. (2012). CSL biotherapies Australia is taking extra steps to ensure the safe use of
Fluvax [influenza virus vaccine] in young children. Reactions Weekly, 32, 2.
McAlister, F., Levine, M., Zarnke, K., & Campbell, N. (2012). Canadian recommendations for the
management of hypertension. Canadian Journal of Cardiology, 17(5), 543-559.
Moser, M. (2014). . World Health Organization-International Society of Hypertension guidelines
for the management of hypertension—Do these differ from the U.S. recommendations?
Which guidelines should the practicing physician follow? journal of clinical hypertension,
1, 48-54.
Olson, K. (2011). poison and drug overdose. Mc graw hill, 5, 32.
Pohl, J. (2011). Smoking cessation and low-income women: Theory, research, and
interventions. Nurse Practice Forum, 11(2), 101-108.
Rajinikanth, A. (2012). nursing assessment. Application of Nursing Process and Nursing
Diagnosis, 12(1), 18-43.
Rosenstein, N., & Perkins, B. (2010). Update on Haemophilus influenzae serotype b and
meningococcal vaccines. Pediatric Clinics of North America, 47(2), 337-348.
Shay, L., & Freifield, A. (2013). The current state of infectious disease: A clinical
perspective on antimicrobial resistance. Lippincott’s Primary Care Practice, 3(1),
1-17.
Shlaes, M., Gerding, D., John, J., & Bronstein, D. (2014). Society for healthcare
epidemiology of America and the Infectious diseases society of america joint
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committee on the prevention of antimicrobial resistance. Guidelines for the
prevention of antimicrobial resistance in hospitals. Infection Control and Hospital
Epidemiology, 18, 275-291.
Truesdell, S. (2014). Helping patients with COPD manage episodes of acute shortness of
breath. med surge nursing, 94(4), 178-182.
Zaragoza, M., Salles, M., Gomez, J., & Trilla, A. (2012). Handwashing with soap or
alcoholic solutions? A randomized clinical trial of its effectiveness. American
Journal of Infection Control, 27, 258-261.
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