NUR251 Assessment 1 S2 2019 Assignment stemplate.

NUR251 Assessment 1 S2 2019
Assignment template
Task 1
Initially, the patient will be assessed for medical history and examination of vital
signs to collect baseline data such as Respiration Rate, SpO2, Blood Pressure,
Pulse, cognitive status and temperature. His urine will be assessed for every 4-6
hours. This assessment will result into formation of nursing diagnoses to identify
any alterations in the body mechanism and urine elimination. Physical
assessment and medical history are the effective tools to assess this disease
(Rickman, 2014). The assessment may be recorded in the patient observation
chart, his progress note and the care plan.
Secondly, the pain assessment will be done using PQRST scale, in terms of scale
of intensity, palliative or provocative factors, duration, quality, radiation and
location of pain. This assessment will identify the level of discomfort and may
disclose the developing complications (Rickman, 2014).
Thirdly, the patient will be assessed to identify the Midstream Urine (MSU), for
dipstick and culture and Urine Microscopy. Positive dipstick reflects nitrite and
leukocyte positive results. Also, Urine microscopy will find out the bacterial
colony count and white cell count. This assessment will help in detecting the
intensity of infection. The assessment may be recorded in documents like
pathological and lab reports.
David will be examined through Ultrasound or intravenous pyelography to assess
the local abnormalities and complications in renal system such as renal infarct,
renal abscess, hydronephrosis and perinephric collections (Agency for Clinical
Innovation, 2019). The ultrasound will act as first line tool for evaluation of
urinary tract and urinary bladder. It will help detect the obstructions, edema or
hemorrhage. Ultrasound and intravenous pyelography tests will help in clearly
differentiating the Pyelonephritis from lower urinary tract infection (Dielubanza,
Matulewicz & Schaeffer, 2018).
The assessment may be recorded in patient’s medication chart and observation
chart.
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Task 2
Nursing Care Plan: David Smith
Nursing problem: Acute Pain
Related to: Infection and inflammation of urinary tract, urinary bladder and the urethra.
Goal of care Nursing interventions Rationale Evaluation
Reduce David’s
pain and increase
comfort
Assess David’s description of pain
severity through PQRST scale.
Give Analgesic like Paracetamol
and Morphine
Practice the non pharmacological
approaches to reduce pain
Apply the heating pads on painful
area
PQRST scale provides pain
assessment in terms of
Provoking factors, Quality,
Radiation, Severity and Time
(Hui & Bruera, 2014).
Pain as reported is flank pain,
burning on urination,
suprapubic and abdominal
pain. Pain assessment will
assist in planning further
interventions.
Paracetamol and Morphine
lowers down the pain
immediately (Jain, Kumar &
Tyagi, 2012).
Non pharmacological
interventions like Distraction,
guided imagery and relaxation
techniques may reduce pain
(Agency for Clinical Innovation,
2019)
David appears to be more relaxed
and comfortable.
He is less complaining through
verbal and non verbal
communication.
He reported that his Right Flank
pain has reduced to 1/10.
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Recommend David not to smoke
and consume alcohol.
Heating pads improve
relaxation of muscles and
mitigate perineal pain (Hui &
Bruera, 2014).
Smoking and alcohol intake
elevate the irritation of urinary
system (Emergency Care
Institute, 2019)
Nursing problem: Risk of fluid imbalance
Related to: Renal Failure
Goal of care Nursing interventions Rationale Evaluation
Improve the
decreased urine
output and ensure
that David’s body
fluids are
maintained
Input and Output of fluids should
be recorded accurately while
keeping in records the hidden
fluids like liquid medicines and IV
fluids. His routine ward
assessments and observations are
done
Encourage the adequate oral
intake of fluids to eliminate kidney
obstruction.
Assessment of fluids I/O will
identify the persistent
imbalance (Weekes, 2015). The
fluid intake should balance the
urine excretion.
Obstruction of flow of urine
may develop post renal
damage. Relief from
obstruction recovers the
normal kidney function (Field &
Pollock, 2010). Old age diabetic
patients having history of
kidney diseases are at greater
His Urine output has been
maintained at > 30 ml per hour
and he is more relaxed now.
His laboratory records and I/O
fluids are within normal limits
During the discussions with Nurse,
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