Nursing Assignment: Systematic Assessment Framework and Nursing Considerations in Medication Administration

This nursing assignment discusses the importance of clinical case studies, health assessment, and geriatric assessment in nursing practice. It also covers the ABCDEFGHI framework for systemic health assessment, the five rights of safe medication administration, and nursing considerations for administering Metaprolol, Digoxin, and Furosemide. Ethical, legal, and professional considerations are also discussed.

Running head: NURSING ASSIGNMENT
Nursing assignment
Name of the Student
Name of the University
Author note

1
NURSING ASSIGNMENT
Clinical case studies are important and act as instructive examples that describes the
background of a patient, determine diagnosis and indicate plan of treatment. It provides a broader
understanding of the patient’s condition and possible outcomes. Health assessment is an
important component in nursing practice that is intended to provide patient-centred care.
According to Nursing and Midwifery Board of Australia (NMBA), nursing assessment is a
competency standard for the registered nurses (Ross, Barr & Stevens, 2013). They need to
perform systematic and comprehensive nursing assessments and plan of care through
interdisciplinary approach to respond effectively to rapidly changing or unexpected situations.
Patient-centred approach forms the basis for health assessment that is helpful in developing an
integrated or coordinated plan along with follow-up for maximizing positive health outcomes
(Kitson et al., 2013). This is witnessed in the clinical case study of Mr. Walter Williams, an 83-
year-old man who had fracture in his left neck of femur (NOF) and underwent total jip
replacement (THR). Later, he recovered in Post-Anesthetic Care Unit (PACU) and currently
placed in Orthopedic Surgical Inpatient Unit (PACU). During the clinical handover, the patient
was found to have complained about pain; however, PACU staff did not give him analgesia due
to hypotension and assumed that he was not in too much pain. This poses ethical and legal
considerations involved in the case study. Therefore, in this assignment, systematic assessment
framework would be conducted relevant to Walter William’s medical condition, nursing
considerations in medicine administration and legal, ethical and professional issues that is related
to the case scenario.
As illustrated in the case study, comprehensive and systematic geriatric health
assessment is important, as it is an interdisciplinary, multi-dimensional and collaborative
approach in nursing (Tavassoli et al., 2014). It is considered a framework for diagnostic process

2
NURSING ASSIGNMENT
for determining the medical, function al and psychological capabilities of elderly people in order
to develop integrated plan of care with possible outcomes. In addition, geriatric assessment help
clinicians to implement care plan that is patient-centered so that there is reduction of functional
decline while supporting independence and improving the overall quality of life.
ABCDEFGHI framework for systemic health assessment is used for the systemic assessment of
trauma patients. The tool is useful in emergency cases. The main purpose of the assessment is to
preserve the life of the patient through proper actions. There are two parts of the assessment;
primary and secondary. ABC is included in the primary survey and DEFGHI is the part of
secondary survey. Once the patient reach life threatening condition, the health professionals must
begin the secondary survey (Peacock, 2004). In the given case study, during the clinical
handover, systematic health assessment is required to understand Walter’s condition and
document for further use.
(A) Airway is the first step of assessment. In this process head tilt chin lift technique is used in
order to open airway. The process could help in the case of Walter to identify any blocked
airway that could lead to cardiac or respiratory attack (Donovan-Kicken et al., 2013).
(B) Breathing: After the airway is opened, next it is important to check breathing by using the
look, listen and feel techniques. In case of Walter, it is important to look at the chest in order to
observe rising and falling of his normal respiration, listen to the air movement and feel the air
coming out of the nose or mouth. If breathing problem is detected then it is important to initiate
CPR (Peabody, 2015).

3
NURSING ASSIGNMENT
(C) Circulation: Without breathing oxygen in the blood cannot be circulated. Thus, it is
important to check blood circulation to detect whether the oxygenated blood circulated
throughout the body in an effective manner (Peacock, 2004).
(D) Disability: It is important to check disability in case of Walter as he had a fall in his
workplace. X-ray report has confirmed the fracture in the left neck of femur. Thus, further
neurological status needs to be observed in order to recognize any disabilities or deformities
within the patient (Liu et al., 2012).
(E) Expose and examine: Detail examination of patient’s body is important to identify any
critical sign. In this regards it is important to remove the clothe and assess properly the patient,
however the patient must be kept warm (Peacock, 2004).
(F) Full set of vital sign is important to document changes in the pulse rate, blood pressure,
pupil breathing, skin color, body temperature, any rashes, and level of consciousness in order to
understand the current situation of the patient and use the report in further treatment (Donovan-
Kicken et al., 2013).
(G) Give comfort measure: As the patient has undergone major operation it is important to give
comfort measure. Continue rest is needed to provide to the patient in order to ensure fast
recovery and prevent further injury (Liu et al., 2012).
(H) History and head-to-toe assessment: A total head-to-toe assessment needs to be done in
order to gather information regarding the health condition of the patient and identify further
treatment if needed. To collect patient history SAMPLE framework could be follow which
includes assessment of symptoms, allergies, medications, past medical history, last oral intake
and events. In case of Walter it has been found that he has morphine allergy, thus, such

4
NURSING ASSIGNMENT
assessment is required to provide adequate care and proper treatment that help the patient to
recover in an effective manner (Benkedjouh et al., 2015).
(I) Inspect posterior surface: Furthermore, inspection for any wound, discolorations and
deformities is important to document Walter’s health condition (Smith, Loftus & Levett-Jones,
2013).
The five rights of safe medication administration are aimed at reducing the medication
harms and errors and ensure medication safety. It uses “five rights”: right patient, right drug,
right dose, the right route and the right time. The name of the patient should be double checked
with name of the medication along with checking of name on medication form against
medication name. The medications should be given from pharmacy labelled container and the
label should be read three times when medication is removed from cabinet, during medication
preparation and returning back to cabinet. The standard measuring devices should only be used
for assuring proper dosage. The time of medication should also be checked like when it was
given last time and determine time of next administration. The medication may be given before
and after 30 minutes after the ordered time. The route of medication should also be checked like
inhaled, mouth, eye or ear drops (Kim & Bates, 2013).
The medication preparation and administration are predominantly a nursing duty that aids
in reducing medication errors ensuring patient safety. Three checks are outlined for safe
medication administration and three times checking is done to ensure whether the medication
label match with the Medication Administration Record (MAR). For the first time, medication
label is checked to MAR while acquiring medication. The second time matching is done while
preparing the medication and finally, the third check is done at the bedside, just before medicine

5
NURSING ASSIGNMENT
administration (Raban & Westbrook, 2014). If the medication label matches with the MAR, the
medication will be administered to the patient and in case of non-matching, it will be withhold
by the nurse.
Metaprolol or Betaloc is antihypertensive and beta-adrenergic antagonist (sympatholytic)
that is given to reduce heart rate and cardiac output at rest by inhibiting beta2 receptors acting as
beta-adrenergic blocking agent (To et al., 2013). This is a high alert medication and can cause
heightened risk because of medication error. For geriatric population, the recommended dosage
is PO 25 mg in case of hypertensive patients. Various nursing indications are required for safe
administration of this drug. As the patient has allergic reactions, it should be used cautiously and
the nurse should monitor BP and take note of apical pulse before the administration. During IV
administrations, it is also important to monitor heart rate (HR < 45 beats/min) and ECG
carefully. As Mr. Walter is hypertensive with congestive heart failure (CHF), it is important to
monitor him closely for impending heart failure and look for symptoms like night cough,
dyspnoea and oedema (Zarrinkoub et al., 2013). Before administration, significant changes in the
vital signs like rhythm, rate, BP or quality of pulse should be evaluated (Garg, 2014). The nurse
should also consider the physical parameters like skin condition, weight, respiratory status, renal
function, and urine and blood glucose. The nurse should also consider the side effects of the drug
like fatigue, weakness, drowsiness, dizziness, blurred vision, loss of appetite, nausea and sleep
patterns.
Digoxin or Lanoxin increases cardiac output having a positive inotropic effect and slow
down heart rate having negative chronotropic effect. It is recommended that this drug should be
used cautiously in geriatric population as it is sensitive to toxic effects and therefore, dosage
adjustments should be made as per age and as body weight and renal function. It is important for

6
NURSING ASSIGNMENT
the nurse to look for any side effects like nausea, vomiting, dizziness, headache and loss of
appetite (Bavishi, Khan & Ather, 2015). The nurse should also consider the potential drug
interactions prior to the drug therapy. While administering in geriatric population, the renal
functioning should also be considered with careful monitoring of side effects. Before
administration, factors like age, body weight and concomitant drugs should be considered as
digoxin toxicity levels are higher than therapeutic levels. The signs and symptoms of digoxin
toxicity like vomiting, nausea, cardiac arrhythmia and visual changes need to considered after
administration. This drug has a narrow therapeutic index and therefore, it is important to increase
monitoring of digoxin concentrations along with potential signs and symptoms of toxicity (Ziff
& Kotecha, 2016). This drug is excreted by kidney and therefore, there are risks of toxic
reactions. Therefore, while administering drug, care should be taken regarding dose selection and
monitor renal functioning.
Furosemide inhibits chloride and sodium re-absorption in the proximal and distal renal
tubules and loop of Henle having antihypertensive effects that decreases the intravascular
volume and oedema (Kapelios et al., 2015). The dosage need to be considered depending upon
the age as in adults 40 mg is the recommended dosage. The nurse should observe the patient
carefully before administering the drug and monitor vital signs and BP as sudden death could
occur from cardiac arrest. The nurse should monitor BP prior to drug administration and look for
diuresis periods and dosage adjustments when required. While administering this drug in older
patients, they need to be observed closely during periods of brisk diuresis. This is important as
sudden alterations in electrolyte and fluid balance can result in potential adverse effects that
require immediate physician reporting (Chawla et al., 2013). The nurse should observe I & O
pattern and ratio and there should be prompt reporting if there is unusual decrease or increase in

7
NURSING ASSIGNMENT
output (Oh & Han, 2015). The patient’s weight should be monitored and signs of excessive
diuresis like hypovolemia and dehydration should be considered with monitoring of blood and
urine glucose levels.
In the given case study, ethical, legal and professional considerations are involved.
When Mr. William complained of pain, the PACU RN did not provide him analgesia, as he is
hypotensive and did not bother to look into his intensity and cause of pain. Considering this
situation, there is violation of legal, ethical and professional standards in nursing that might have
hampered patient dignity and safety (Johnstone, 2015).
Non-maleficence is the ethical principle that is governing negligence in the case scenario
where the PACU RN was not capable of performing the pain assessment and providing
appropriate pain management intervention to relieve the patient from pain. After critically
analysing the case scenario of Mr. William, it is clear that negligence was the leading cause that
would have exacerbated further development of complications due to post-operative pain after
THR. It is evident that Mr. William was in conscious state as he woke to the nurse voice and
answered simple questions, but returned to sleep after the nurse stopped talking to him. During
his conscious state, he complained of pain, however, the nurse did not perform any pain
assessment and rather ignored his condition stating that he did not seem to be in much pain. This
scenario clearly depicts that there is tort of negligence that might have involved harm where the
nurse failed to act because of negligence and carelessness (Barker et al., 2012). The nurse failed
to exercise reasonable care for her actions that inflicted potential harm caused to others. In
nursing, the ethical principle of non-maleficence states that nurses should not do any harm and
tied to duty of protecting patient’s safety (Johnstone, 2015). Considering the situation, the nurse
hampered patient safety by neglecting the pain that the patient complained that might have been

8
NURSING ASSIGNMENT
life threatening. Another ethical principle, respect for autonomy was also violated as Mr.
William have a right to self-determination and despite of complaining pain, the nurse did not
acknowledge his condition that might have resulted in adverse events.
The Nursing and Midwifery Board of Australia (NMBA) legislation under the Health
Practitioner Regulation National Law (2009) regulates nursing and midwifery profession in
Australia effective from March 2018. It set legislation and competencies that are prescribed
under National Law 2009 required to fulfil the requirements of nursing and midwifery
profession in Australia. This law regulates the clinical practice of nurses where they need to
protect patients from harm who are suitably qualified and trained in practicing their profession in
an ethical and competent manner (Fitzgerald, Burrell & Bull, 2012). In the case scenario, the
nurse failed to work ethically that inflicted harm hampering patient safety.
Under Standard 6 of NMBA, RN standards of practice, it is stated that nurses have the
responsibility to provide appropriate, safe, responsive and ethical nursing practice to achieve
agreed outcomes for the patients. RNs should perform comprehensive and quality nursing that is
responsive towards needs of the patients (Standard of practice, Nursing and midwifery board of
Australia, 2018). Under Conduct Statement 10, NMBA Code of Professional Conduct for
nurses in Australia, nurses should practice nursing ethically demonstrating appropriate and
quality nursing care (Standard of practice, Nursing and midwifery board of Australia, 2018).
They should evaluate their competency and work reflectively that contribute to professional
nursing practice. Nurses have the obligation to work in accordance and in the given case study,
the PACU RN violated the professional standards where she did not use appropriate process to
identify the cause of his pain and report the risk that would have inflicted demonstrating below
level expected nursing standards. Therefore, in the case scenario, the nurse should have

9
NURSING ASSIGNMENT
performed in accordance with the nursing professional standards, ethical principle, legislation
and guidelines.
From the above clinical case study of Mr. Walter Williams, it is evident that nurses
should perform health assessment while working in accordance with the nursing professional
standards, legislation and code of ethics. NMBA provides a framework for safe nursing and
midwifery practices in Australia for possible outcomes and patient safety. Therefore, during
clinical handover, geriatric health assessment was conducted through systematic framework by
Shelley Peacock that helped in guiding nurses in developing an integrated plan that fulfil patient
needs. Pain assessment was done through VNRS that helped in assessing his pain levels based on
score scales. Moreover, as the patient is allergic, nursing considerations were also outlined in
context to Mr. Walter’s medications that helped in avoiding adverse reactions in drug
administration. He underwent THR and suffered from post-operative pain that the nurse
neglected assuming that the patient is not in much pain. This resulted in violation of ethical, legal
and professional standards in nursing practice comprising of non-maleficence and tort of
negligence, Health Practitioner Regulation National Law (2009) and NMBA standards of
practice respectively. Therefore, through the case study of Mr. Walter Williams, it is clear that
nurses should work in accordance with the nursing professional standards and code of ethics.

10
NURSING ASSIGNMENT
References
Barker, K., Cane, P., Lunney, M., & Trindade, F. (2012). The law of torts in Australia. Oxford
University Press. Retrieved from: https://espace.library.uq.edu.au/view/UQ:266941
Bavishi, C., Khan, A. R., & Ather, S. (2015). Digoxin in patients with atrial fibrillation and heart
failure: a meta-analysis. International journal of cardiology, 188, 99-101.
DOI: https://doi.org/10.1016/j.ijcard.2015.04.031
Benkedjouh, T., Medjaher, K., Zerhouni, N., & Rechak, S. (2015). Health assessment and life
prediction of cutting tools based on support vector regression. Journal of Intelligent
Manufacturing, 26(2), 213-223. Retrieved from https://hal.archives-ouvertes.fr/hal-
00867582/document
Chawla, L. S., Davison, D. L., Brasha-Mitchell, E., Koyner, J. L., Arthur, J. M., Shaw, A. D., ...
& Seneff, M. G. (2013). Development and standardization of a furosemide stress test to
predict the severity of acute kidney injury. Critical care, 17(5), R207. DOI:
https://doi.org/10.1186/cc13015
Donovan-Kicken, E., Mackert, M., Guinn, T. D., Tollison, A. C., & Breckinridge, B. (2013).
Sources of patient uncertainty when reviewing medical disclosure and consent
documentation. Patient education and counseling, 90(2), 254-260. DOI:
https://doi.org/10.1016/j.pec.2012.10.007
Fitzgerald, J., Burrell, C., & Bull, P. (2012). Health practitioner regulation national law act 2009:
Attitudes and compliance of the chiropractic profession one year on. Chiropractic

11
NURSING ASSIGNMENT
Journal of Australia, 42(2), 51. Retrieved from:
https://search.informit.com.au/documentSummary;dn=784940788962282;res=IELHEA
Johnstone, M. J. (2015). Bioethics: a nursing perspective. Elsevier Health Sciences. Retrieved
from: https://books.google.co.in/books?
hl=en&lr=&id=4dRQCgAAQBAJ&oi=fnd&pg=PP1&dq=Johnstone,+M.+J.+(2015).
+Bioethics:+a+nursing+perspective.
+Elsevier+Health+Sciences.&ots=YEvE_YuLbk&sig=tI2NxputYFuGPmwoar68fjw_FW
c#v=onepage&q=Johnstone%2C%20M.%20J.%20(2015).%20Bioethics%3A%20a
%20nursing%20perspective.%20Elsevier%20Health%20Sciences.&f=false
Kapelios, C. J., Kaldara, E., Ntalianis, A., Sousonis, V., Repasos, E., Sfakianaki, T., ... &
Terrovitis, J. V. (2015). High furosemide dose has detrimental effects on survival of
patients with stable heart failure. Hellenic J Cardiol, 56(2), 154-159. Retrieved from:
http://hellenicjcardiol.org/archive/full_text/2015/2/2015_2_154.pdf
Kim, J., & Bates, D. W. (2013). Medication administration errors by nurses: adherence to
guidelines. Journal of Clinical Nursing, 22(3-4), 590-598. Doi:
https://doi.org/10.1111/j.1365-2702.2012.04344.x
Kitson, A., Marshall, A., Bassett, K., & Zeitz, K. (2013). What are the core elements of patient‐
centred care? A narrative review and synthesis of the literature from health policy,
medicine and nursing. Journal of advanced nursing, 69(1), 4-15. DOI:
https://doi.org/10.1111/j.1365-2648.2012.06064.x
Liu, S. S., Buvanendran, A., Rathmell, J. P., Sawhney, M., Bae, J. J., Moric, M., ... & Shin, N. S.
(2012). Predictors for moderate to severe acute postoperative pain after total hip and knee

12
NURSING ASSIGNMENT
replacement. International orthopaedics, 36(11), 2261-2267. DOI:
https://doi.org/10.1007/s00264-012-1623-5
Nursing and Midwifery Board of Australia - Registered nurse standards for practice.
(2018). Nursingmidwiferyboard.gov.au. Retrieved 3 July 2018 from
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-
standards/registered-nurse-standards-for-practice.aspx
Oh, S. W., & Han, S. Y. (2015). Loop diuretics in clinical practice. Electrolytes & Blood
Pressure, 13(1), 17-21. DOI: https://doi.org/10.5049/EBP.2015.13.1.17
Peabody, F. W. (2015). The care of the patient. Jama, 313(18), 1868-1868. DOI:
10.1001/jama.2014.11744
Peacock, S. (2004). Systematic health assessment: A case study. Practice Nursing, 15(6), 270-
274. DOI: https://doi.org/10.12968/pnur.2004.15.6.13155
Raban, M. Z., & Westbrook, J. I. (2014). Are interventions to reduce interruptions and errors
during medication administration effective?: a systematic review. BMJ Qual Saf, 23(5),
414-421. Doi: http://dx.doi.org/10.1136/bmjqs-2013-002118
Ross, K., Barr, J., & Stevens, J. (2013). Mandatory continuing professional development
requirements: what does this mean for Australian nurses. BMC nursing, 12(1), 9. DOI:
https://doi.org/10.1186/1472-6955-12-9
Smith, M., Loftus, S., & Levett-Jones, T. (2013). Teaching clinical reasoning. In Educating
Health Professionals (pp. 269-276). SensePublishers, Rotterdam. DOI:
https://doi.org/10.1007/978-94-6209-353-9_23

13
NURSING ASSIGNMENT
Standard of practice, Nursing and midwifery board of Australia. (2018). Retrieved 3 July, 2018
from http://file:///C:/Users/user00/Downloads/1798150_1830561517_Nursing-and-
Midwifery-Board---.PDF
Tavassoli, N., Guyonnet, S., Van Kan, G. A., Sourdet, S., Krams, T., Soto, M. E., ... & Cestac, P.
(2014). Description of 1,108 older patients referred by their physician to the “Geriatric
Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability” at the
gerontopole. The journal of nutrition, health & aging, 18(5), 457-464. DOI:
https://doi.org/10.1007/s12603-014-0462-z
To, T. P., Story, D. A., Booth, J., Nielsen, F., Heland, M., & Hardidge, A. (2013). Oral
Medication Administration in Patients with Restrictions on Oral Intake—A Snapshot
Survey. Journal of Pharmacy Practice and Research, 43(3), 177-181. DOI:
https://doi.org/10.1002/j.2055-2335.2013.tb00249.x
Zarrinkoub, R., Wettermark, B., Wändell, P., Mejhert, M., Szulkin, R., Ljunggren, G., & Kahan,
T. (2013). The epidemiology of heart failure, based on data for 2.1 million inhabitants in
Sweden. European journal of heart failure, 15(9), 995-1002. DOI:
https://doi.org/10.1093/eurjhf/hft064
Ziff, O. J., & Kotecha, D. (2016). Digoxin: The good and the bad. Trends in cardiovascular
medicine, 26(7), 585-595. DOI: https://doi.org/10.1016/j.tcm.2016.03.011