Medical Surgical Nursing Assessment
Added on 2021-04-17
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Page1Medical Surgical Nursing
Page2Task 1: Patient assessmentMedical assessment of Jim need to be carried out in different conditions like hypertension,breathing insufficiency and infection. Hypertension assessment need to be carried out in Jimbecause it is evident that he is suffering through hypertension. According to handoverinformation, recorded blood pressure of Jim is 158/86 mmHg. This blood pressure is morethan normal blood pressure and it can be measured by using sphygmomanometer. Bloodpressure can change based on the activity, hence it should be measured both at rest and postactivity (Dewit, Stromberg, and Dallred, 2016). Infection can increase WBC count in patient,hence WBC estimation need to be carried out in Jim. Along with this, sputum analysis alsoneed to be carried in Jim for the presence of Influenza A virus because he is infected withinfluenza A virus. Jim is exhibiting insufficient breathing, hence breathing pattern andbreathing rate need to be assessed in him. Moreover, in influenza infected patients,respiratory tract gets affected which can affect functioning of respiratory system. It can leadto insufficient breathing (White, Duncan, and Baumle, 2012).Early assessment of infection, hypertension and insufficient breathing can be useful inplanning suitable intervention for Jim. Identification of infected organism can be helpful inadministering specific antibiotic. In Influenza infected patients, infection can deterioraterespiratory tract, hence insufficient breathing can occur. This insufficient breathing can bedue to inflammation and consequent oedema of the respiratory tract. This lead to problem ofinsufficient breathing in Jim which reduces oxygen saturation level. To compensate thislowered oxygen level, heart need to pump forcibly to supply required amount of oxygen(Berman, et al., 2014). It results in the hypertension in Jim. It is necessary to assess and planrequired intervention for infection, hypertension and breathing insufficiency in Jim becauseall these conditions are interrelated and can exaggerate each other. All these conditions canaffect adversely physical and physiological state of Jim (Shannon, Dirksen and Heitkemper,2013).
Task 2: Care planningNursing Care Plan: JimNursing problem: Risk of spread of infectionUnderlying cause or reason: Influenza virus is contagious in nature and it can be easily spread to the immunosuppressed patients in the hospital.Goal of careNursing interventions/actionsRationaleIndicators your plan is workingTo prevent spread ofinfluenza infection andto control it in thehospital facility.Assessment of influenza infection byculturing sputum and nasal secretionssamples.Carry out WBC counting.Encourage patient to use mask duringspeaking, coughing and sneezing.Inform Jim to clean hands with suitableantiseptic and decontaminate articles usedby him. Inspire patient for wearing glovesand gown.Make arrangements for the patient in theisolated place and stop him to go to thecrowded places throughout the period ofinfection.Early assessment can be helpful inplanning early intervention (Carpenito,2013).Infection can lead to increase in WBCcount (Lemone et al., 2017)Mask can prevent spread andtransmission of infecting organism (Liet al., 2014)Indirect spread of infection can beprevented by washing hands withantiseptic and decontaminating usedarticles (Patel et al., 2014; Manfrediand D'Onofrio, 2013). Isolated environment prevents spread ofinfection (Patel et al., 2014; Manfrediand D'Onofrio, 2013). Absenteeism of symptoms for influenzainfection.Absence of virus in the culture samples ofsputum and nasal secretion sample.
Nurse should consult with doctor andadminister suitable antibiotic to him.Antibiotic administration can be helpfulin prevention and control of infection(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 inspire patient toperformroutineactivities. Reduces risk ofrespiratoryinsufficiencyandperformingdailyactivities normally. Assess his ability to perform day to dayactivities. Make available him walker to walk withoutfall.Assist him in performing his activities. Provide comfortable environment for himso that he would not feel uncomfortable indoing activities. Allow him to perform his activities at hiswill without putting pressure.Inspire family members to assist him incarrying out his activities. Monitor vital signs prior to and postactivities and assess relative changes in theEarly assessment is useful in planningintervention to improve his capability(Gulanick and Myers, 2016).Limited assistance to the patient canimprove his self-sufficiency (Seed and Torkelson, 2012). Self-respect, self-esteem and dignity ofthe patient can be improved (Seed andTorkelson, 2012).Early signs of deterioration can bemonitored effectively (Doenges,Moorhouse and Murr, 2016; Yates etal., 2014)Stress for the completion of activitiescan be reduced and risk of fall can bereduced (Doenges, Moorhouse andMurr, 2016; Yates et al., 2014)Jim performed daily activities with easewithout distress of impaired respiratoryfunctioning..
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