NUR250 Medical Surgical Assignment
Added on 2021-04-17
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Page1NUR250 Medical Surgical Nursing1Double click here to fill in this footerLast name__ _student number_NUR250 S1 2018 Assessment 1
Page2Task 1: Patient assessmentJim need to be assessed for hypertension, breathing insufficiency and infection. It is requiredto assess blood pressure in Jim because provided data indicates he is exhibiting hypertension.According to provided handover his blood pressure is 158/86 mmHg. Blood pressureassessment can be done by measuring blood pressure by using sphygmomanometer. Bloodpressure measurement need to be done at rest position and after activity. Blood pressuremeasurement need to be performed in lying position and standing position. Assessment ofinfection can be done by performing WBC count because in infection there can be raisedWBC count. In assessment of other types of infections, differential count can be usefulhowever, in influenza differential count cannot give accurate assessment. Assessment ofinfection can be performed by culturing sputum samples for the presence of influenza virus.Assessment for insufficient breathing need to be performed in Jim. Insufficient breathing canbe performed by estimating respiratory rate and measuring oxygen saturation (Dewit et al.,2016).Assessment of infection is necessary in Jim because based on severity and type of infection,nursing intervention can be planned for Jim. Accurate antibiotic need to be given to Jimbecause infection can be controlled by specific antibiotic only. Uncontrolled infection canexaggerate the condition in John because it lead to insufficient breathing and hypertension.Infection of nasal cavity can lead to inflammation and edema in the nasal cavity. It caninterfere with breathing pattern which can lead to lowered oxygen saturation. Loweredoxygen saturation level can force heart to pump forcibly which can lead to hypertension. Allthese conditions are interrelated and can influence each other. Hence, these conditions needto be assessed in Jim because it can affect physical, physiological and psychologicalwellbeing of Jim (Berman, et al., 2014).2Double click here to fill in this footerLast name__ _student number_NUR250 S1 2018 Assessment 1
Task 2: Care planningNursing Care Plan: JimNursing problem: Risk of spread of infectionUnderlying cause or reason: Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immunocompromised patients in thehospital setting are at higher risk of contracting disease resulting in adverse events.Goal of careNursing interventions/actionsRationaleIndicators your plan is workingTo prevent and controlthe spread of influenzawithin the healthcarefacility and thecommunity.Assess risk of infection by culturingsputum samples.Perform WBC counting.Encourage patient to wear mask duringcoughing and sneezing.Educate patient about maintaining hygieniccondition including washing hands with theantiseptic solution. Decontaminateaccessories used by the patient.Encourage patient to wear gown andgloves.Keep patient in the isolated environmentand Prevent patient to go to the places untilinfection persists.Assessment of risk of infection can behelpful in planning early intervention(Carpenito, 2013).In infection there can be increasedWBC counting (Lemone et al., 2017)Wearing mask can be helpful inreducing risk of direct spread ofinfection (Li et al., 2014)Maintaining hand hygiene anddecontaminating accessories can behelpful in reducing indirect spread ofinfection (Patel et al., 2014; Manfrediand D'Onofrio, 2013). It can be helpful in preventing infection(Patel et al., 2014; Manfredi andD'Onofrio, 2013). Absence of virus in the sputum sample.Absence of symptoms related to infection.3Double click here to fill in this footerLast name__ _student number_NUR250 S1 2018 Assessment 1
Administer suitable antibiotic afterconsultation with physician.Isolation of patient can be helpful inpreventing spread of infection from oneperson to another (Patel et al., 2014;Manfredi and D'Onofrio, 2013)Administration of antibiotic can behelpful preventing infection in the earlystage, hence its spread can be prevented(Patel et al., 2014; Manfredi andD'Onofrio, 2013).Nursing problem: Self care deficitUnderlying cause or reason: Fatigue due to dyspnoeaGoal of careNursing interventions/actionsRationaleIndicators your plan is workingTo encourage Jim toperform activities ofdaily living likebathing,clothing,eating etc.Assess capability of Jim to preformactivities of daily living.Provide walker or support whenever Jimwishes to walk.Provide assistance to Jim to perform hisactivities.Provide independent surrounding for Jim,hence he can perform his activities withouthesitation. Encourage Jim to perform activities at hiswill.Encourage participation of family membersAssessment can be helpful in planningearly intervention to improve hisactivity level (Gulanick and and Myers,2016).Restricted assistance to patient can behelpful to become self-sufficient (Seedand Torkelson, 2012). It can be helpful in improving self-esteem and dignity of the patient (Seedand Torkelson, 2012).Jim is performing activities with theminimal assistance.Jim is performing activities of daily living,cleaning teeth, taking bath and clothing.4Double click here to fill in this footerLast name__ _student number_NUR250 S1 2018 Assessment 1
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