Nursing Interventions

Running head: NURSING INTERVENTIONS
NURSING INTERVENTIONS
Name of the Student
Name of the University
Author Note

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NURSING INTERVENTIONS
Initial Assessment of the Nurse
In case of Mr. Yellow, 23 year old patient with amputation in right foot and burned chest,
abdomen and both arms as a result of motor vehicle accident admitted for surgery in a hospital
and post surgery he was transferred to the medical surgical unit. Here the nurse has to assess his
condition by means of his body temperature, his response to the pain and the consciousness of
the patient as well. After assessment comes the diagnosis step of nursing process where the nurse
need to report the responses of the patient to the doctor and on the basis of doctor’s consent the
nurse should be able have some clinical judgments for the interventions of the patient. These
clinical judgements would be assisting the further steps of the nursing process that are the
planning and implementation. The diagnosis process needed to consider the basis physiological
needs of the patient along with safety and security as well. On the other hand the planning would
be able to set some goals for the intervention process of the patient and the goals would be
considering the specificity, time, measurable actions along with attainable and realistic actions.
The implementation process would comprise of all these steps as it requires assessment,
diagnosis and planning (Toney-Butler & Thayer, 2018).
Care Plan for Five Days
At day 2 when the patient suffered from severe pain in the right foot him which was
amputated at the accident. On the basis of his condition the doctor prescribed daily change of the
stump dressing twice a day in order to relieve his pain and controlling the situation. Thus the
nurse would need to support the patient in this critical situation and observe his condition in an
hourly basis. The nurse also needed to plan a care process that would be able to comfort the
patient as well. In times of his excessive pain the nurse would be able to medicate him with pain

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NURSING INTERVENTIONS
killer and change the stump dressing as well to comfort his pain. However, before planning the
diagnosis from the nurse would be needed and the diagnosis would comprised of 4 conditions
which are impaired mobility, risk factor of infection, risk factor of infective tissue growth and
low self-esteem of the patient. In order to solve the problem the nurse would be able to verbally
empower the patient and help in recovery from his low self-esteem and motivate him in mobility
as well. Along with pain killer medication the nurse should be able to use some process to
prevent the infection to grow as well (Chung et al., 2015).
Initial Action of the Nurse at Day Five
In case of Mr. Yellow he suffered from severe burns in his body and also amputation in
the right foot as well. Thus after surgery a large amount of blood and plasma loss could be the
cause of the hypovolemic shock for the patient thus the fever of 102.5o C resulted ate 5th day after
operation of the patient (Lucas, 2019). This assessment of the patient’s condition would be
expected from the nurse and according to this assessment the nurse should be able to stabilise the
condition of the patient. The initial action of the nurse would be contacting the doctor and
stabilise the patient’s condition through providing saline to stabilise his blood fluid concentration
and also preventing fluid loss from the body. However, the amputation of right foot would be
able to develop an infection thus the immunological factors of the body would be attracted to that
point thus the fever can be caused by this condition as well. All these assessments would be
diagnosed by the nurse with the use of CT scan for any kind of internal bleeding detection, blood
test for the detection of the blood fluid level and the detection of infectious element in the blood.
All these assessments and diagnosis would be reported to the doctor as well in order to prevent
the hypovolmic shock of the patient and stabilise the feverish condition of him as well (Daviaud
et al., 2015).