NUR251 Assessment 1 S2 2019 Assignment Template

NUR251 Assessment 1 S2 2019
Assignment template
Please note: As indicated in Assessment 1 information, a cover sheet, title
and contents pages are not required
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Task 1
The given case study is about a 72 years old man Mr. David Smith. He was admitted
to the hospital because of acute kidney failure having hyperlipidemia, being an ex-smoker,
chronic kidney disease stage 3 and anxiety. At the time of admission, he was having high
fever, decreased output of urine and flank pain. Assessment of the renal failure patient begins
with performing an initial assessment to detect and treat threats to life.
The first assessment that has to be completed is the head to toe assessment, the
medical history and the observations are required to gather the comprehensive baseline data.
With the consent of the patient and maintaining the privacy and the ongoing communication,
the body temperature, the rate of decrease in urine output has to be assessed. The patient was
suffering from pyelonephritis which means he had suffered from infections in the lower
urinary tract, so the infection rate should be assessed (Grams et al., 2016). An observation
chart has to be maintained for noting the progress of David.
The next assessment should be conducted by using the PQRST algorithm. This
assessment has to be conducted to relief the patient from the sufferings of pain as providing
the patient with adequate pain relief will assist in increasing the physical and mental comfort
of the patient (Gordon et al., 2016). These assessments also has to be noted in the observation
chart of the patient.
The next assessment which is to be done is to assess the extremities of oedema. If the
patient is bedridden, the oedema gets accumulated posteriorly in the pre sacral area. The
patient of the given case study has been suffering from oedema in the calves. For assessing
the oedema, the nurse need to compress on the soft tissue of the patients with the thumb and
the indentations must be observed. Another assessment which is required to be done is
checking whether he is suffering from uremic frost on the skin or not. Uremic frost is the
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deposit of urea in powdered form and uric acid on the surface of skin. The nurse must
regularly note progress of the patient.
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Task 2
Nursing Care Plan: David Smith
Nursing problem: Acute Pain
Related to: Related to the acute kidney failure.
Goal of care Nursing interventions Rationale Evaluation
Minimising the pain
and ensuring that
David’s comfort is
maintained.
 Assessing David’s pain by using
PQRST algorithm.
 Properly monitoring the verbal and
nonverbal communication with the
patient regarding pain, involving the
criteria of analgesic requests,
moaning, facial grimacing, guarding
and wincing.
 The using of the intensity
scale of pain is very
consistent, easy and reliable
method to determine the
intensity of pain of the
person (Manworren, 2015).
 Appropriate verbal and
nonverbal communication is
 The patient appears to be
much more comfortable and
he himself accepted this.
 The number of required
anesthesia also got reduced.
 David told that his pain score
also got reduced.
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