NUR254 Vital Singh Assessment 2022

NUR251 Assessment 1 S2 2019
Assignment template
Task 1
The following three assessment of David’s condition will be necessary at
the start of shift based on review of his major health issues and current
symptoms:
1.
Vital sign assessment: Vital sign assessment will be necessary for David to
detect changes in the area of breathing, circulation, elimination, disability
or changes in physical state of patient. As David is suffering from acute
kidney injury, vital signs data will help to collect cues regarding signs of
clinical deterioration, renal impairment and risk of infection. This will to
prioritize nursing interventions for recovery of David (Sherwood et al.,
2018). If this assessment is not done, then it will be difficult to evaluate
signs of kidney function impairment just by normal appearance of
patients. The documentation of vital signs can be done using ABCDE
(Airway, breathing, circulation, disability and elimination) checklist as it
helps to document findings separately for each of the five areas (Smith &
Bowden, 2017).
2.
Fluid imbalance assessment: David is a patient with acute kidney injury
and this condition impairs regulations of the water homeostasis function of
the kidney resulting in reduced urine output, oedema and reduction in
glomerular filtration rate (GFR). Hence, fluid imbalance assessment is
necessary to identify extent of kidney impairment and monitor changes in
urine output, skin integrity, GFR value and implement appropriate
treatment that can prevent water retention and reduce symptoms of
edema (Lim et al., 2016). If fluid balance assessment is not done, then
water retention issues and signs of fluid accumulation may go unnoticed
resulting in delay in treatment. This assessment can be documented using
a fluid balance chart.
3.
Pain assessment: David is found to be restless and worried because of left
flank pain. Because of this symptom, pain assessment is necessary to
evaluate severity of pain, location, frequency and level of pain. This can
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help to identify whether pain is an ongoing issue for patient or it occurs
because of other inter-linked condition. It will also help to analyse the
impact of pain on mobility and gait patterns of patient (Raina, Krishnappa
& Gupta, 2018). The consequences of avoiding pain assessment are that
it can result in poor resolution of pain and patient may continue to be in
discomfort throughout the hospital stay. Pain assessment results can be
documented using the PQRST (Provokes, quality, radiates, severity and
time) pneumonic which a common method for recording pain assessment
findings (Raina, Krishnappa & Gupta, 2018).
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Task 2
Nursing Care Plan: David Smith
Nursing problem: Acute Pain
Related to: right flank pain and fatigue due to pain
Goal of care Nursing interventions Rationale Evaluation
To provide pain
relief, decrease
anxiety due to
pain and provide
comfort to student
1. Assess pain using PQRST
algorithm
2. Observe patients to find
non-verbal signs of pain and
discomfort due to this
3. Administer pain medications
like analgesics
4. Provide education to patient
regarding the cause of pain,
the purpose of pain
medication and the
expected benefits from
pharmacological
interventions
5. Implement non-
1. This assessment is
necessary to get idea
about severity, timing
and frequency of pain.
The data obtain through
this assessment can help
in implementing
appropriate pain
management
interventions (Raina,
Krishnappa & Gupta,
2018)
2. Non-verbal cues related
to patients facial
expressions like signs of
Pain score has now reached 0
Patient shows no signs of facial
grimaces now and has no problem
in changing positions
Patient is satisfied with overall care
experience
The patient will be free to mobilize
and no effect on gait found
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pharmacological
interventions like heat packs
and warm shower to reduce
pain
6. Changing position of patient
and providing relaxation
techniques
7. Discussing side-effects of
medication with patients
and the importance of
notifying changes to nurse.
grimaces, moaning, poor
movement or inactivity
can indicate the impact
of pain on emotional and
physical functions of
patient. This can help to
identify other
adjustments needed
apart from
pharmacological (Gélinas,
2016).
3. Pain medications like
NSAIDs and other
analgesics reduce the
level of chemical
mediators and
inflammation that leads
to inflammation and pain
(Zhan et al., 2017).
4. Patients are emotionally
distressed due to pain
because they are not
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aware regarding the
cause of pain and they
are clueless regarding
the medications given to
them. Education in this
area can develop positive
attitude towards
treatment in patient
(Briggs, 2012)
5. The significance of using
cold pack is that it
reduces inflammation
and stiffness due to pain
(Davis, 2019).
6. Relaxation technique is
effective in promoting
perseverance and
patience in client
experiencing pain
symptoms
7. It will help to identify any
complications on time
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(Akbas et al., 2016)
Nursing problem: Risk of fluid imbalance
Related to: decreased urine output and bilateral pitting edema
Goal of care Nursing interventions Rationale Evaluation
To reduce fluid
retention problem
and prevent
accumulation of
fluid in the body
1. Conduct assessment of skin
integrity, turgor and mucous
membrane
2. Conduct assessment
regarding fluid intake, urine
output, types of IV
administered and
documented in fluid
balanced chart
3. Observe for sign and
symptoms of dyspnea,
headache and level of
consciousness
4. Assess breathing pattern of
patient and auscultate lungs
5. Maintain appropriate fluid
intake and educate patient
1. The importance of this
assessment is that it can
indicate areas of swelling
or accumulation of fluid
and pale cool skin which
are the first sign of fluid
imbalance (da Silva et al.,
2013)
2. Assessment of urine
output is critical to rule
out hypovolemia or
hypervolemia (Bleyer,
2014).
3. Presence of these
symptoms are indication
of fluid imbalance in
patient (Ohashi et al.,
Normal urine output is seen
No changes in weight
Symptom of edema has
disappeared
No cough and absence of
symptoms of headache and
breathing problems
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