Nursing Assignment Assessment 2022

Nursing Assignment
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Task 1:
First assessment will be performed for physical and vital signs assessment. Physical
and vital signs assessment will be performed through carrying out several
procedures such as observation, palpation, percussion and auscultation. These
assessments will be beneficial in identifying signs and symptoms of current medical
condition of David
(Gabayan et al., 2017). It has been observed that values obtained for the vital signs
for David are the abnormal values because these are outside the normal values of
vital signs. Hence, to confirm normalisation of values of vital sings; it is necessary to
carry out vital sign assessment in David (Gabayan et al., 2017). If vital signs
assessment would not have been carried out in David; it would have been difficult to
plan specific intervention for the abnormal vital sign values. Data obtained through
physical and vital signs assessment will be recorded in charts such as observation
chart, medication chart and progress notes.
Second assessment will be performed for the fluid balance in case of David. Fluid
balance will be assessed trough incorporating different parameters like determination
of administered fluid volume, cardiac rhythm and neurological manifestations
(Prowle, Kirwan, and Bellomo, 2014). It is essential to carry out fluid balance
assessment in case of David because fluid imbalance is prominent manifestation of
AKI. In case of not performing fluid balance in David; there would be possibility of
accumulation of water and salt (Prowle, Kirwan, and Bellomo, 2014). Data obtained
through assessment of fluid balance will be recorded in different charts like fluid
balance chart, daily weight chart, fluid prescription chart and medication chart.
Third assessment will be performed for the acute pain for David. It necessary to
carry out acute pain assessment in David because it is one of the most prominent
symptoms of AKI. Adult patients like David are usually not willing to verbalise their
pain sensation. Hence, specific intervention for the management of pain might not be
provided for such patients. Acute pain assessment will be performed using PQRST
scale (Coluzzi, 2018). Data obtained through acute pain assessment will be recorded
in different charts such as observation chart, progress notes and medication chart.
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Task 2
Nursing Care Plan: David Smith
Nursing problem: Acute Pain
Related to: Acute kidney injury
Goal of care Nursing interventions Rationale Evaluation
Minimise pain
sensation in David.
Improve awareness of David about the
identification of pain sensation,
encourage him to report it immediately
and acknowledge his concerns.
Assist David in re-positioning and
mobilisation.
Monitor non-verbal communication of
David.
Immediate reporting of pain is
attributable to the early intervention.
Untreated pain can produce varied
psychological issues like anxiety
and depression. Exchange of
information between the patient and
nurse can improve therapeutic
relationship among them which
would be helpful in providing
person-centred care for the effective
management of pain
(Duke, Botti, and Hunter, 2012).
Assistance in re-positioning and
mobilisation can be helpful in
minimising muscle discomfort, fall
risk and injury (Duke, Botti, and
Hunter, 2012).
Elder patients like David are not
willing to verbalise their pain
sensation. Hence, non-verbal
communication can be helpful in
assessing the intensity of pain
Recorded pain score for David is 2/10.
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Improve awareness of David about the
pain medication, ensure David is
consuming pain medications on regular
basis and monitor effectiveness and
adverse effects of pain medicines.
sensation (Pham et al., 2017).
Management of pain can be
effectively achieved through
administration of pain medicines.
Regular monitoring of pain
medicines is beneficial in improving
effectiveness and reducing adverse
effects because pain medications
are associated with several
psychological side-effects (Pham et
al., 2017).
David reported pain relief after
consumption of pain medication.
Nursing problem: Risk of fluid imbalance
Related to: Urine retention and AKI
Goal of care Nursing interventions Rationale Evaluation
Administer adequate
amount of fluid and
maintain
normovolumic
condition.
Update, observe and monitor fluid
prescription chart and fluid balance
chart.
Ensure availability of varied safety
measures such as soft restraints and
side rails and improve awareness of
David about use of these safety
measures.
Take body weight of David on regular
basis and enter the data in progress
report.
These charts will give idea about
the volume of administered fluid and
requirement of volume of fluid.
Hence, accurate amount of fluid can
be administered without producing
hypovolemic or hypervolumic
condition (McGloin, 2015).
Fluid imbalance is responsible for
the development of pitting oedema;
hence risk free mobilisation can be
achieved through use of these
safety measures (McGloin, 2015).
Unexpected change in the body
weight is indication of fluid
imbalance (Pinnington, Ingleby,
Normovolumic condition maintained.
Signs and symptoms of fluid imbalance
are not evident.
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