NUR250 Assessment 1 SS 2019 Assignment template

NUR250 Assessment 1 SS 2019
Assignment template
Task 1
As per the handover report, the patient named, Mrs Rose Wilson aged 57
years who has been suffering from Compulsive Obstructive Pulmonary Disorder
(COPD). She has been a patient of dyspnoea and was heeled in with the
symptoms of cough and a fever. She lives with her husband and has a history of
smoking 20 cigarettes per day. In addition to this, she is also an avid drinker who
religiously drinks one glass of wine during dinner. When asked about any
reported allergies, she declined. She is observed to be mildly obese with her BMI
around 30. During the initial assessment conducted by the nurse, the saturated
level of oxygen has been found to be 89 % which is below the normal range. Her
blood pressure is 160/95 mmHg which could be inferred as stage 1 hypertension
(van Gestel & Steier, 2010). She scored full 15 out of 15 on the4 Glasgow Coma
Scale which revealed her condition to be very serious with complains of sharp
inconsistent pain on the chest. However, her body temperature has been
measured to be around the range of normal, that is, 38.6 oC.
Considering the situation of the patient in the hospital, an assessment was
conducted while a chest X-Ray was ordered which would have revealed the
congestion on the chest and lungs of the patient because of which there is a
difficulty in breathing (Berry et al., 2015). The nursing professionals have been
instructed to manage the chest pain in the patient and administer the
medications as are reported by the physician. It is revealed that she has been on
salbutamol and metformim which are drugs helping to regulate the blood sugar
and prevent blocking of the airway to the lungs. She has a history of suffering
from type 2 diabetes mellitus for which she has been taking these medications.
In addition to the previously administered medications, considering the
seriousness of the medical condition, she has been prescribed some new
medications like amoxicillin and ceftriaxone. These two are the medications
which are prescribes to patients who have a tendency to contract serious
bacterial infections. As the patient is suffering from COPD, it is likely that the
patient will be contracting infections.
When a patient complains of suffering from COPD, there is a high chance
that the airway passage to the lungs of the individual is blocked with cough
(Macklem, 2010). The capillaries that transfer the oxygenated air are lined
around the lungs which may have lost their stretchiness. The damage that is
1
Double click here to fill in this footer
Lastname__ _student number_NUR250 SS2019Assessment 1

caused to the airway sacs and the capillaries tend to block the passage for the
air to pass and the patient experiences difficulty in breathing (Wells & Dransfield,
2013).
2
Double click here to fill in this footer
Lastname__ _student number_NUR250 SS2019Assessment 1

Task 2
Nursing Care Plan: Mrs Rose Wilson
Nursing problem: Acute Pain
Related to: COPD is a dynamic lung sickness wherein side effects like persevering hack and chest snugness can cause
torment. COPD-related agony is generally situated in the shoulders, neck, lower back, and chest. Furthermore, the blend of
agony, tension, trouble dozing, and inconvenience breathing can negatively affect your personal satisfaction.
Goal of care Nursing interventions Rationale Evaluation
As a nursing
professional, it is a
goal to decrease
the amount of pain
that is felt by the
patient during the
times of coughing
and breathing
difficulties.
Showing chest physiotherapy, for
example, bronchial tapping during
coughing, legitimate postural
seepage (Gyself & Higginson,
2011). Exhibit powerful hacking
and profound breathing systems.
Watch attributes of hack
(determined, hacking and soggy).
Help with measures to improve
the viability of hack exertion
(Saunders, 2015).
Hack can be tenacious however
insufficient, particularly if the
patient is older, intensely sick,
or incapacitated. Hacking works
effective in upright or head-
down position after chest
percussion (Janssen et al.,
2011). Such devices should
avoid potential impulses to
prevent any untoward
misunderstanding, and further
help to improve airflow.
Manual chest physiotherapy (MCP)
includes outer control of the thorax
utilizing percussion and vibration
procedures (Simonelli et al., 2019).
Their motivation of these is too
discontinuous to apply motor
vitality to the chest divider to
remove bronchial emissions. The
patient at that point clears these
emissions with an expiratory move,
for example, the constrained lapse
method (FET). The supposition
basic the utilization of MCP is that
expelling sputum from the aviation
route improves ventilation
perfusion proportions and in this
way lung work.
Nursing problem: Risk of ineffective tissue perfusion
Related to: Hypoventilation due to COPD. Mechanical reduction of venous and/or arterial blood flow
Goal of care Nursing interventions Rationale Evaluation
Understanding
takes part in
practices or
activities to
Check for ideal liquid equalization.
Regulate IV liquids as requested.
Think about the requirement for
potential embolectomy,
Adequate liquid admission
keeps up sufficient filling
pressures and upgrades
cardiovascular yield required
The goal is achieved when the
symptoms are not visible in the
patient and her condition is
significantly improving.
3
Double click here to fill in this footer
Lastname__ _student number_NUR250 SS2019Assessment 1

improve tissue
perfusion. Quiet
verbalizes or
shows typical
sensations and
development as
fitting.
heparinization, vasodilator
treatment, thrombolytic
treatment, and liquid salvage.
for tissue perfusion. These
encourage perfusion when
impedance to blood stream
comes to pass or when
perfusion has gone down to
such a genuine level prompting
ischemic harm.
Nursing problem: Anxiety
Related to: the inconsistent pain and the perceived symptoms of COPD.
Goal of care Nursing interventions Rationale Evaluation
The primary goal
of the nurse is to
reduce the levels
of anxiety in
patients such that
a better health
outcome is
ensured.
It is the responsibility of the
nursing professional to
acknowledge the difficulties of the
patient regarding the increasing
anxiety levels and deduce
interventions. One of the
interventions that could be used
by the nurse is to implement
relaxation therapy by the
incorporation of talking about the
past traumas and playing soft
music in the background. This will
help the patient in relaxing their
muscles and concentrate on the
betterment of the medical
condition.
It has been observed that using
relaxation techniques with the
help of music therapy can help
in decreasing the anxiety levels
in patients.
As per the relaxation technique, it
is observed that patients do feel
relaxed at the end of the session
after drifting themselves to
peaceful areas.
Task 3
4
Double click here to fill in this footer
Lastname__ _student number_NUR250 SS2019Assessment 1