Nursing Care Plans and Medical-Surgical Nursing

This assignment involves creating a list of references related to nursing care plans and medical-surgical nursing. The sources include textbooks, journals, and online resources. The task requires identifying relevant publications, articles, and websites that provide comprehensive information on nursing care plans, transitional patient and family-centered care, constipation management, medical-surgical nursing concepts, and more. The assignment aims to help students in their studies by providing a list of reliable sources for research and learning.

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Medical Surgical Nursing

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Task 1: Patient assessment
Medical 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 Jim
because it is evident that he is suffering through hypertension. According to handover
information, recorded blood pressure of Jim is 158/86 mmHg. This blood pressure is more
than normal blood pressure and it can be measured by using sphygmomanometer. Blood
pressure can change based on the activity, hence it should be measured both at rest and post
activity (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 also
need to be carried in Jim for the presence of Influenza A virus because he is infected with
influenza A virus. Jim is exhibiting insufficient breathing, hence breathing pattern and
breathing 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 lead
to insufficient breathing (White, Duncan, and Baumle, 2012).
Early assessment of infection, hypertension and insufficient breathing can be useful in
planning suitable intervention for Jim. Identification of infected organism can be helpful in
administering specific antibiotic. In Influenza infected patients, infection can deteriorate
respiratory tract, hence insufficient breathing can occur. This insufficient breathing can be
due to inflammation and consequent oedema of the respiratory tract. This lead to problem of
insufficient breathing in Jim which reduces oxygen saturation level. To compensate this
lowered 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 plan
required intervention for infection, hypertension and breathing insufficiency in Jim because
all these conditions are interrelated and can exaggerate each other. All these conditions can
affect adversely physical and physiological state of Jim (Shannon, Dirksen and Heitkemper,
2013).

Task 2: Care planning
Nursing Care Plan: Jim
Nursing problem: Risk of spread of infection
Underlying cause or reason: Influenza virus is contagious in nature and it can be easily spread to the immunosuppressed patients in the hospital.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To prevent spread of
influenza infection and
to control it in the
hospital facility.
Assessment of influenza infection by
culturing sputum and nasal secretions
samples.
Carry out WBC counting.
Encourage patient to use mask during
speaking, coughing and sneezing.
Inform Jim to clean hands with suitable
antiseptic and decontaminate articles used
by him. Inspire patient for wearing gloves
and gown.
Make arrangements for the patient in the
isolated place and stop him to go to the
crowded places throughout the period of
infection.
Early assessment can be helpful in
planning early intervention (Carpenito,
2013).
Infection can lead to increase in WBC
count (Lemone et al., 2017)
Mask can prevent spread and
transmission of infecting organism (Li
et al., 2014)
Indirect spread of infection can be
prevented by washing hands with
antiseptic and decontaminating used
articles (Patel et al., 2014; Manfredi and
D'Onofrio, 2013).
Isolated environment prevents spread of
infection (Patel et al., 2014; Manfredi
and D'Onofrio, 2013).
Absenteeism of symptoms for influenza
infection.
Absence of virus in the culture samples of
sputum and nasal secretion sample.

Nurse should consult with doctor and
administer suitable antibiotic to him.
Antibiotic administration can be helpful
in prevention and control of infection
(Patel et al., 2014; Manfredi and
D'Onofrio, 2013).
Nursing problem: Self care deficit
Underlying cause or reason: Fatigue due to dyspnoea
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To inspire patient to
perform routine
activities.
Reduces risk of
respiratory
insufficiency and
performing daily
activities normally.
Assess his ability to perform day to day
activities.
Make available him walker to walk without
fall.
Assist him in performing his activities.
Provide comfortable environment for him
so that he would not feel uncomfortable in
doing activities.
Allow him to perform his activities at his
will without putting pressure.
Inspire family members to assist him in
carrying out his activities.
Monitor vital signs prior to and post
activities and assess relative changes in the
Early assessment is useful in planning
intervention to improve his capability
(Gulanick and Myers, 2016).
Limited assistance to the patient can
improve his self-sufficiency
(Seed and Torkelson, 2012).
Self-respect, self-esteem and dignity of
the patient can be improved (Seed and
Torkelson, 2012).
Early signs of deterioration can be
monitored effectively (Doenges,
Moorhouse and Murr, 2016; Yates et
al., 2014)
Stress for the completion of activities
can be reduced and risk of fall can be
reduced (Doenges, Moorhouse and
Murr, 2016; Yates et al., 2014)
Jim performed daily activities with ease
without distress of impaired respiratory
functioning..

vital signs.
Inspire patient to take rest in between
activities.
On consultation with doctor provide
artificial oxygen to the patient.
Extend emotional support to the patient to
keep his self-esteem high to complete his
activities.
Enough rest period can restore energy
and lessen the risk of fatigue (Doenges
et al., 2016; Yates et al., 2014)
Improve functioning of respiratory
system which can be helpful in
reducing risk of fatigue (Bailey et al.,
2012)
Self-confidence can be improved to
perform the activities after discharge
from the hospital (Potter et al., 2013
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: Insufficient fluid intake and loss of fluid due to vomiting.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To maintain adequate
fluid balance and
maintain hydration in
Jim.
Maintain fluid intake and output chart for
him.
Record body weight on regular basis.
Record vital signs like blood pressure,
respiratory rate and temperature on regular
basis.
Monitor oral mucosa and skin turgor for
assessment of dryness.
Use Glasgow coma scale for orientation
Chart can be helpful in assessing
requirement of fluid (McGloin, 2015).
Symptoms of abnormal vital signs like
tachypnoea, hypotension and
tachycardia reflects insufficient intake
of fluid and risk of dehydration
(McGloin, 2015).
Dryness of oral mucosa and skin turgor
signs reflects dehydration in the patient
(McGloin, 2015).
Jim started consuming enough amount fluid
according to his requirement.
No abnormality in oral mucosa and skin
turgor.

assessment. Altered electrolyte balance can lead to
altered orientation in the patient
(McGloin, 2015).
Nursing problem: Risk of anxiety and depression.
Underlying cause or reason: Due to hypertension and insufficient breathing, patient can develop anxiety and depression.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To verbalize anxiety
and depression in Jim.
To provide counselling
for anxiety and
depression.
Assessment of level of anxiety and
depression.
Assessment of physical reflections to
depression and anxiety.
To provide counselling to relieve from
anxiety and depression.
Assessment of level of anxiety can be
helpful in providing appropriate care in
timely manner (Carpenito, 2013;
Gulanick and Myers, 2016).
Anxiety and depression can produce
symptoms like weakness and dizziness
(Carpenito, 2013; Gulanick and Myers,
2016).
Panic and threatening situation can be
avoided in Jim (Carpenito, 2013;
Gulanick and Myers, 2016).
Jim verbalizes problems related to anxiety
and depression.
Improved thought process and functioning
of Jim
Nursing problem: Risk of constipation.
Underlying cause or reason: Insufficient intake of diet.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Jim has defecation with
ease.
Evaluate stool consistency and determine
frequency of it.
Abnormal defecation can be evaluated
in Jim (Costilla and Foxx-Orenstein,
2014).
Normal and natural defecation can be
Normal defecation on regular basis.
Stools are normal and well-formed.
Jim is stress-free during defecation.

Inspire Jim to take warm water on the daily
basis.
Make sure that Jim is taking nutritious food
on the regular basis.
Nurse should consult with doctor and
prescribe him with bulk laxatives.
ensured in Jim (Costilla and Foxx-
Orenstein, 2014).
Normal elimination can be maintained
by relieving constipation in Jim
(Costilla and Foxx-Orenstein, 2014).
Fluid intake can be helpful in soften the
stools and solid diet can be helpful to
improve stool consistency (Costilla and
Foxx-Orenstein, 2014).

Task 3: Medication management:
Oseltamivir is an antiviral agent. It can be useful for treating both Influenza A and Influenza
B virus. It is necessary to take it within 48 hours of infection to stop infection. After its
administration, nurse need to monitor symptoms of influenza like fever, cough, headache,
fatigue, muscular weakness and sore throat. Hence, nurse can assess effectiveness of
oseltamivir in Jim. If there is no improvement in these symptoms, nurse need to consult with
doctor to change dose or type of medication. Oseltamivir can exhibit psychological side
effects; hence nurse need to monitor behavioural changes in Jim to understand psychological
state of Jim (Skidmore-Roth, 2015; Tiziani, 2013).
Paracetamol can be useful in patients with pain and fever. Handover data indicate that Jim is
having fever. Temperature in Jim need to be monitored after administration of paracetamol.
Paracetamol is available in combination drugs also. Nurse need to monitor whether Jim is
consuming another drug containing paracetamol. If his fever is not going to be reduced after
three days of paracetamol administration, nurse need to consult with doctor to change dose of
paracetamol. Paracetamol should not be consumed on empty stomach; hence he need to take
paracetamol after taking proper diet. Patients consuming paracetamol are susceptible to
develop liver toxicity and liver damage. Hence, nurse need to perform liver function test in
Jim (Skidmore-Roth, 2015; Tiziani, 2013).
Fluvax is vaccine useful in preventing influenza infection. Fluvax need to be administered
every year, so that its effectiveness can be improved in prevention and eradication of
influenza virus. It can produce its effects for the longer duration because antibodies produced
due to this virus can be active for more than 6 months. Patients taking Fluvax need to be
assessed for anaphylactic hypersensitivity to egg and other components of vaccine
(Skidmore-Roth, 2015; Tiziani, 2013).
Task 4: Patient teaching:
Transmission of influenza can be categorised into direct and indirect transmission. In direct
transmission, Influenza virus can be transmitted through coughing and sneezing. In indirect
transmission, Influenza virus can be transmitted through hand contacts and use of articles
handled by influenza patients. Nurse should educate Jim about washing hands on regular
basis with antiseptic and decontaminating articles used by him. He should use mask, gloves
and gown. Jim should be aware of signs and symptoms of influenza; hence he can inform the
same to the nurse. It would be helpful in planning early intervention for him. Prevention of
infection is important for Jim and others because it can be helpful in preventing its spread.

Hence, there would be less burden on the hospital for the treatment of influenza. As a result,
Jim can receive satisfactory treatment and risk of re-infection can also be reduced in Jim.
Treating re-infection is difficult because once used antibiotic cannot be effective for Jim.
Prevention of influenza infection is important in Jim because influenza infection can
deteriorate Jim by affecting his respiratory system (Morton and Fontaine, 2017). Nurse need
to provide theoretical and practical education to Jim about prevention of infection. Jim need
to adhere to prevention of infection and nurse need to monitor this process on continuous
basis. Jim need to use suitable antiseptic for his hands and articles used by him. He should
use all the PPEs like mask, gloves and while coming in contact with other people. He should
be in isolated environment throughout the period of infection (Jardins and Burton, 2015;
Beachey, 2018).
Task 5: Clinical judgement and handover
Influenza virus infection can lead to impaired functioning of the respiratory system. In case
of Jim also, respiratory system gets deteriorated. Hence, it leads to impaired functioning of
the lungs and impaired gaseous exchange between alveoli wall and capillary wall interface.
This leads to reduced oxygen saturation and deficient supply of oxygen to different organs of
the body. As a result of reduced supply of oxygen, heart need to pump at faster rate to
achieve normal oxygen saturation level. This can lead to increased heart rate and blood
pressure. Breathing rate also gets raised to maintain normal oxygen saturation level. It results
in the increased respiratory rate and increase in the body temperature. Due to increase in body
temperature, Jim is experiencing shivering. Slow and deep breathing can be helpful in
managing his respiratory problems and ensure that he is following these breathing techniques.
On consultation with doctor, antihypertensive, bronchodilator and antipyretic medicines need
to be administered to him Immediate intervention can be helpful in the improvement in the
vital signs like blood pressure, respiratory rate, heart rate and control of body temperature.
Abnormality in these vital signs can lead to multiple organ damage in Jim. Hence, to prevent
multiple organ deterioration; immediate intervention is required for managing these
conditions.
I am a nursing student in the medical-surgical ward. I am worried about patient Jim. After
administration of medicines, there is improvement in his influenza A infection. Despite this,
he became restless in the morning and he was shivering. After assessment, he was with
abnormal breathing and with reduced response to speech. His observed vital signs were
temperature 39.6̊C, heart rate 125 bpm, respiratory rate 24 bpm, blood pressure 124/79
mm/Hg and oxygen saturation 86 %. Watchful monitoring of the Jim is required. Doctor’s

team assessed the Jim’s condition and refereed to the High Dependency Unit to provide
BIPAP.

References:
Bailey, P. H., Boyles, C. M., Cloutier, J. D., Bartlett, A., Goodridge, D., Manji, M., & Dusek,
B. (2012). Best practice in nursing care of dyspnea: The 6th vital sign in individuals
with COPD. Journal of Nursing Education and Practice, 3(1), 108. doi:
https://doi.org/10.5430/jnep.v3n1p108 .
Beachey, W. (2018). Respiratory Care Anatomy and Physiology: Foundations for Clinical
Practice. Elsevier Health Sciences.
Berman, A., Shirlee, J. S., Barbara, K., ….. Stanley, D. (2014). Kozier & Erb's Fundamentals
of Nursing Australian Edition. Pearson Higher Education AU.
Carpenito, L. J. (2013). Nursing Care Plans: Transitional Patient & Family Centered Care.
Lippincott Williams & Wilkins.
Costilla, V.C., and Foxx-Orenstein, A.E. (2014). Constipation: understanding mechanisms
and management. Clinics in Geriatric Medicine, 30(1), 107-15.
Dewit, S. C., Stromberg, H., and Dallred, C. (2016). Medical-surgical Nursing: Concepts &
Practice. Elsevier Health Sciences.
Doenges, M. E., Moorhouse, M. F., and Murr, A. C. (2016). Nurse's Pocket Guide:
Diagnoses, Prioritized Interventions, and Rationales. F.A. Davis.
Gulanick, M., and Myers, J.L. (2016). Nursing Care Plans - E-Book: Nursing Diagnosis and
Intervention. Elsevier Health Sciences.
Jardins, D., and Burton, G. G. (2015). Clinical Manifestations & Assessment of Respiratory
Disease - E-Book. Elsevier Health Sciences.
Manfredi, P., and D'Onofrio, A. (2013). Modeling the Interplay Between Human Behavior
and the Spread of Infectious Disease. Springer Science & Business Media
McGloin, S. (2015). The ins and outs of fluid balance in the acutely ill patient. British
Journal of Nursing, 24(1). doi: 10.12968/bjon.2015.24.1.14
Morton, P. G. and Fontaine, D. K. (2017). Critical Care Nursing: A Holistic Approach.
Lippincott Williams & Wilkins.
Lemone, P., Burke, K., Bauldoff, G., Gubrud, P., Levett-Jones, T., Hales, M., … Reid-Searl,
K. (2017). Medical-surgical nursing, critical thinking for person-centred care. (3rd
Australian ed.). Melbourne, Victoria: Pearson Australia.
Patel, D.B., Emmanuel, N.B., Stevanovic, M.V., Matcuk, G.R.. Jr, Gottsegen, C.J., Forrester,
D.M., and White, E.A. (2014). Hand infections: anatomy, types and spread of
infection, imaging findings, and treatment options. Radiographics, 34(7), 1968-86.
Potter, P.A., Perry, A. G., Stockert, P., and Hall, A. (2013). Fundamentals of Nursing - E-
Book. Elsevier Health Sciences.
Seed, M.S., and Torkelson, D.J. (2012). Beginning the recovery journey in acute psychiatric
care: using concepts from Orem's Self-Care Deficit Nursing Theory. Issues in Mental
Health Nursing, 33(6), 394-8.
Shannon, S. L., Dirksen, R., and Heitkemper, M. M. (2013). Linda Bucher Medical-Surgical
Nursing: Assessment and Management of Clinical Problems. Elsevier Health
Sciences.
Skidmore-Roth, L. (2015). Mosby's Drug Guide for Nursing Students. Elsevier Health
Sciences.
Tiziani, A. P. (2013). Havard’s nursing guide to drugs (9th ed.). Elsevier Health Sciences.
White, L., Duncan, G., and Baumle, W. (2012). Medical Surgical Nursing: An Integrated
Approach. Cengage Learning.
Yates, T., Davies, M.J., Edwardson, C., Bodicoat, D.H., Biddle, S.J., and Khunti, K. (2014).
Adverse responses and physical activity: secondary analysis of the PREPARE trial.
Medicine & Science in Sports & Exercise, 46(8), 1617-23.