NUR250 Medical Surgical Nursing: Patient Assessment & Care Plan

This assignment provides a comprehensive overview of patient assessment and care planning in a medical-surgical setting, focusing on a patient named Jim. It includes an initial assessment covering patient history, vital signs, and physical examination, followed by focused and time-lapsed assessments to monitor the patient's condition and response to treatment. The assignment also details a nursing care plan addressing key problems such as the risk of infection spread (influenza), self-care deficit, risk of imbalanced fluid volume, ineffective breathing pattern, and the risk of nicotine withdrawal. Nursing interventions and rationales are provided for each problem, along with indicators to evaluate the plan's effectiveness. Furthermore, the assignment discusses medication management, specifically oseltamivir, paracetamol and Fluvax, including their mechanisms of action, potential side effects, and nursing considerations.

NUR250 Assessment 1 S1 2018 Assignment template
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Task 1: Patient assessment
Initial assessment that covers patient’s history, vital signs and a head to toe physical
examination. It helps to confirm the symptoms verbalized by the patient. This assessment will
help in identifying the aetiology of Jim’s condition, any underlying conditions, duration of
the symptoms and severity (Wahlin, Lindström, Ponzer, & Vicente, 2018). It helps in
prioritizing plan of care for Jim and identifying the root cause of the condition. In case this
assessment is not well completed, Jim’s care will not be prioritized and facts such as the
contagious nature of the disease might be missed. The symptoms might be missed leading to
exacerbation of the condition leading to fatal complications.
Focused assessment where diagnosis is made and treatment is given under supervision
(DeMaria, Twist & Weeks, 2017). In this assessment, vital signs are monitored regularly as
they point out how Jim is fairing on. This assessment helps in eliminating the differential
diagnosis that may present with similar symptoms of dyspnoea, myalgia, headache,
rhinorrhoea and malaise as Jim’s and point out the main diagnosis to enable monitoring the
progress under treatment to ensure stability of the patient. In case this assessment is not
completed; the primary diagnosis might be missed and the patient will be managed for a
wrong condition.
Time-lapsed assessment is conducted as medications are being administered to find
out the patient’s progress. It starts after a few hours and will continue as long as the patient is
admitted. The conditioned is assessed in comparison with the original state to identify the
change (Cattoli, Trkov & Capote, 2016). Jim will be monitored for any adverse effects of the
medication and whether the medication is working. In case the dyspnea, headaches and
rhinorrhoea do not resolve with treatment, the patient is reassessed and replanning done.
Failure to complete this assessment can lead to patient having unnoticed adverse drug
reactions and the condition may be worsening without attempt to manage it well.
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Task 2: Care planning
Nursing Care Plan: Jim
Note: Dot points recommended in care plan. Click and type in each cell, click enter in a cell to make it longer. Do not remove text from the
template.
A reminder that all rationales must be referenced
Nursing problem: Risk of spread of infection
Underlying cause or reason: Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immunocompromised patients in the
hospital setting are at higher risk of contracting disease resulting in adverse events.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To prevent and control
the spread of influenza
within the healthcare
facility and the
community.
 Administer oseltamivir 75mg Bd
 Wearing of masks and gloves
before coming into contact with the
patient.
 Oseltamivir is an antiviral drug
against influenza virus. It has
the ability to clear an influenza
infection hence rendering Jim
noncontagious (Dobson,
Whitley, Pocock & Monto,
2015).
 Influenza is transmitted through
 Jim’s symptoms of rhinorrhoea,
malaise, dyspnoea subsides.
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 Proper handwashing before and
after coming in contact with the
patient.
respiratory droplets or by
contact with infected surfaces.
Wearing masks and gloves
reduces chance of contracting or
spreading (Varble, Albrecht,
Backes, Crumiller, Bouvier,
Sachs, & García-Sastre, 2014)
 It helps in reducing cross
contamination (Little, Stuart,
Hobbs, Moore, Barnett, Popoola
... & Yao, 2015)
Nursing problem: Self-care deficit
Underlying cause or reason: influenza virus presents with symptoms of malaise and fatigue. This reduces the ability of the patient to take care of himself and
perform daily activities of bathing, walking, and going to the toilet.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To help Jim perform
selfcare activities such
as bathing, walking,
going to the toilet and
 Provide support to the patient when
walking and encourage him to
walk.
 Educate patient on the importance
 Minimum support and education
encourages patient for self-care
(Fivecoat, Sayers & Riegel,
2018)
 Jim is able to perform daily activities
with little or no assistance.
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dress. of independence and assist where
necessary.
 Establish guidelines and goals of
activity with the patient.
 Ensure Jim performs activities of
daily living according to his ability.
 Provide a conducive environment to
enable Jim perform selfcare, e.g. a
clean place to brush teeth.
 Enhances motivation and self-
esteem of the patient (Stamp,
Dunbar, Clark, Reilly, Gary,
Higgins, & Ryan, 2016)
 This increases self-worthiness
and independence hence
achieving the objective of self-
care (Frost, Weingarden, Zeilig,
Nota, & Rand, 2015).
 Jim dresses himself well.
 Jim is well kempt and clean.
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: nausea and vomiting, side effects of oseltamivir Jim is taking and increased metabolism due to fever and the infection.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
 To ensure Jim
demonstrates
normal
hydration status.
 To ensure Jim
 Maintain input and output fluid
chart of the patient.
 Monitor heartrate and blood
pressure.
 It helps identify the hydration
status of the body and fluid
requirement (Jeyapala, Gerth,
Patel, & Syed, 2015)
 Heartrate and blood pressure are
 Jim demonstrates a normal heartrate
ranging between 60-100 beats/min.
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has a normal
heart rate that
ranges between
60-100
beats/min
 Monitor urine output and report
when it is less than 30 mls/ hour.
 Administer métoclopramide 10mg
IV tds.
the indicators of fluid imbalance
and show the severity of the
deficit (Hall, 2015).
 It helps tell when the patient is
dehydrated and requires more
fluid intake when the output is
less than 30mls/hour (Leedahl,
Frazee, Schramm, Dierkhising,
Bergstralh, Chawla, & Kashani,
2014).
 Metoclopramide is a D2
receptor antagonist and speeds
up peristalsis reducing vomiting
(Ong & Felice, 2017).
 A urine output of more than
30mls/hour is attained.
 Jim demonstrates reduced feeling of
nausea and vomiting after
medication
Nursing problem: Ineffective Breathing Pattern
Underlying cause or reason: influenza virus infects the upper and lower respiratory tract, this can lead to inflammation hence irritation and congestion of the
airways leading to shortness of breath.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
 To ensure Jim  Assess vital signs, respiratory rate,  Vital signs are the baseline Jim has a respiratory rate that ranges
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demonstrates
normal
respiratory rate
and pattern.
 To ensure Jim
demonstrates an
oxygen
saturation of
above 95%
pattern and rhythm.
 Administer supplemental oxygen
2L/min.
 Take pulse oximetry readings and
note when the reading is less than
90%.
 Assess for abnormal breath sounds.
indicators for any condition and
they give insight on further
complication (Mok, Wang &
Liaw, 2015).
 Supplemental oxygen helps
relieve symptoms of respiratory
distress (Nishimura, 2015).
 It helps determine arterial blood
gas and gives a picture of tissue
perfusion that can help prevent
tissue ischemia (Diab, Weber&
Ali, 2016).
 Breath sounds help in
identifying the condition and
severity of respiratory
compromise (Davis &
Papachrisanthou, 2017)
between 12-20breaths/min and has no
symptoms of shortness of breath.
Jim has an oxygen saturation above 95%.
No wheeze sound on auscultation
Nursing problem: Risk of Nicotine withdrawal
Underlying cause or reason: Cigarettes have nicotine as a main ingredient that causes addiction. Inability to afford cigarettes deprives the body of nicotine
leading to withdrawal symptoms.
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Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To help patient control
and overcome
withdrawal symptoms
such as insomnia,
irritability, cravings,
depression, restlessness
and anxiety.
 Encourage patient to participate in
physical activities.
 Enrol the patient to a rehabilitation
group.
 Administer nicotine replacement
therapy.
 Advice and counselling sessions for
the patient.
 Participation in physical
exercise helps patient overcome
the cravings of smoking as he
gets preoccupied (Ussher,
Taylor & Faulkner, 2014).
 Rehabilitation groups will help
the patient interact with people
with similar struggles, share
stories and be able to cope up
with withdrawal symptoms
(Gaalema, Cutler, Higgins,
Savage, & Ades, 2015).
 Nicotine replacement therapies
are administered as the dose is
reduced gradually to help the
patient cope with smoking
cessation (Rohsenow, 2017)
 Counselling sessions helps
patient to be able to understand
Jim will be able to have adequate sleep.
Jim will be able to tolerate the cravings of
smoking.
Patient is calm and able to socialise with
other people.
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the symptoms and have a high
self-esteem (Kropff, Petersilka,
Flemmig, Ehmke, Heuft &
Schneider, 2016)
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Task 3: Medication management
Jim has been given oseltamivir 75mg twice a day because it is an antiviral drug for
influenza virus, as it stops the virus from multiplying and relieves symptoms of headaches,
malaise and running nose (Dobson et al., 2015) The nurse should ensure Jim takes the drug
after exactly 12 hours to maintain the drug concentration in the body for better action and
ensure the dose is completed to avoid relapse of the flu. oseltamivir has side effects of nausea
and vomiting, monitor his reaction after taking the medicine and if there are side effects,
administer antiemetics. The nurse should monitor if the side effects are controlled, if they are
not, consult the physician for another prescription.
Oral paracetamol is administered to Jim since it’s an analgesic used to treat mild
pains. Jim has headache caused by the flu hence paracetamol to relief the ache (Mallet,
Eschalier & Daulhac, 2017). The nurse should ensure the patient gets the medication when
need arises and should ensure the Jim doesn’t get the medication for more than 10 days to
avoid toxicity. Side effects to paracetamol are rare. The nurse should monitor patient for any
unusual itchiness, rush or trouble breathing.
Fluvax start dose has been administered to Jim as a vaccine to make him immune to
influenza virus. This prevents future recurrent infection (Ayoola, Sukumaran, Kumar,
Gordon, Roy, Vantandoust & Karapetis, 2016). Nurse should ensure Fluvax is administered
into a muscle and not a vein. Before administering the nurse should take a history whether
Jim had received the vaccine recently or has eaten eggs or is on antibiotics polymyxin and
neomycin, these are contraindications. The nurse should assess whether Jim is
immunocompetent to avoid infecting him from the vaccine. The nurse should perform a
physical assessment on Jim to identify side effects such as inflammation on the injection site,
numbness or abscess formation.
Task 4: Patient teaching
Influenza virus causes an infection of the upper and lower respiratory tract that presents with
symptoms of malaise, running nose, headaches, dyspnoea and fatigue (Davidson, McCabe,
Crotta, Gad, Hessel, Beinke & Wack, 2016). It is transmitted via respiratory droplets from an
infected person or coming in contact with infected surfaces hance regular handwashing
prevents the spread of influenza virus (Yang, Mok, Peiris, & Zhong, 2015). One can transmit
the infection even before showing the symptoms. Wearing masks by people infected and the
ones at risk prevents being infected with the virus. Fluvax, a vaccine that prevents the
contracting the vaccine is available and it is given yearly. Treatment of the individuals
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exposed reduces the chance of spreading the virus. The information must be given to Jim
precisely that influenza virus can be a deadly condition when it complicates as it can lead to
viral pneumonia or sinus infections (Blyth, Macartney, Hewagama, Senenayake, Friedman,
Simpson & Cheng, 2016). Jim must take the medications and complete the dose to avoid
spreading the virus and also avoid recurring in the future. Jim must be advised on the
importance of getting the vaccine each year since the virus keeps mutating. This will help
relief the symptoms preventing and controlling the incidence and spread of influenza.
Task 5: Clinical judgement and handover
Jim has been on medication for influenza but this morning the presenting vital signs, a
high temperature 39.6 ̊ c, a rapid heartbeat of 125beats/min and a high respiratory rate of
24breaths/per min. he is sleeping on and off, diaphoretic, shivering, complains of feeling
cold, restless and curled in bed, has a laboured breathing and is slow to respond when called
upon. Jim has developed withdrawal symptoms of nicotine since he has a habit of smoking up
to 10 packets per a day. Such a situation is considered emergency as the patient cannot
tolerate the symptoms. Reassure the patient to ensure calmness. Encourage the patient to get
out of bed and perform activities to relieve the cravings of cigarrete. Administer supplemental
oxygen to prevent respiratory complications. Administer nicotine supplements reducing the
dosage till the patient can tolerate.
I am a registered nurse from medical surgical ward. I have been taking care of Jim
who is 58 years old. He was admitted with symptoms of myalgia, fatigue, dyspnea, headache
and rhinorrhoea. On examination he was found to have shortness of health, soreness of the
muscle and febrile. He has a history of smoking and was diagnosed with asymptomatic
hypertension with no treatment. A primary diagnosis of influenza was confirmed. He has
been on oseltamivir, paracetamol and had a stat dose of Fluvax. He is allergic to chicken. The
symptoms had decreased till today morning when he appeared unsettled, refusing to get out
of bed and complaining of cold. On examination, he presented with tachycardia
125beats/min, low oxygen saturation of 86%, a fever of 39.6 ̊ c and tachypnoea,
24breaths/min. He is on supplemental oxygen via face mask 2L/min as prescribed and
medication have been administered and are to be continued. Close monitoring is required to
assess his progress. He has been reviewed by the doctors and advised to continue with
management and rest.
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References
Ayoola, A., Sukumaran, S., Kumar, R., Gordon, D., Roy, A., Vantandoust, S., ... & Karapetis,
C. (2016). Efficacy of influenza vaccine (FluVax) in patients on chemotherapy
(POCT): final data analysis from South Australia. Annals of Oncology, 27(suppl_6).
Cattoli, G., Trkov, A., & Capote, R. (2016). Avian influenza viruses at the animal human
interface: Progress and challenges in under resourced countries. International Journal
of Infectious Diseases, 53, 24.
Davidson, S., McCabe, T. M., Crotta, S., Gad, H. H., Hessel, E. M., Beinke, S., ... & Wack,
A. (2016). IFNλ is a potent anti‐influenza therapeutic without the inflammatory side
effects of IFNα treatment. EMBO molecular medicine, 8(9), 1099-1112.
Davis, R. L., & Papachrisanthou, M. L. (2017). Asymmetrical Breath Sounds During
Respiratory Syncytial Virus Season. The Journal for Nurse Practitioners, 13(5),
e255-e257.
DeMaria, R., Twist, M. L., & Weeks, G. R. (2017). Focused genograms: Intergenerational
assessment of individuals, couples, and families. Routledge.
Diab, M. K., Weber, W. M., & Al-Ali, A. (2016). U.S. Patent No. 9,351,673. Washington,
DC: U.S. Patent and Trademark Office.
Dobson, J., Whitley, R. J., Pocock, S., & Monto, A. S. (2015). Oseltamivir treatment for
influenza in adults: a meta-analysis of randomised controlled trials. The
Lancet, 385(9979), 1729-1737.
Fivecoat, H. C., Sayers, S. L., & Riegel, B. (2018). Social support predicts self-care
confidence in patients with heart failure. European Journal of Cardiovascular
Nursing, 1474515118762800.
Frost, Y., Weingarden, H., Zeilig, G., Nota, A., & Rand, D. (2015). Self-care self-efficacy
correlates with independence in basic activities of daily living in individuals with
chronic stroke. Journal of Stroke and Cerebrovascular Diseases, 24(7), 1649-1655.
Gaalema, D., Cutler, A., Higgins, S. T., Savage, P., & Ades, P. (2015). Smoking and cardiac
rehabilitation program completion. Drug & Alcohol Dependence, 156, e76.
Hall, J. E. (2015). Guyton and Hall textbook of medical physiology e-Book. Elsevier Health
Sciences.
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Jeyapala, S., Gerth, A., Patel, A., & Syed, N. (2015). Improving fluid balance monitoring on
the wards. BMJ Open Quality, 4(1), u209890-w4102.
Leedahl, D. D., Frazee, E. N., Schramm, G. E., Dierkhising, R. A., Bergstralh, E. J., Chawla,
L. S., & Kashani, K. B. (2014). Derivation of urine output thresholds that identify a
very high risk of AKI in patients with septic shock. Clinical Journal of the American
Society of Nephrology, CJN-09360913.
Little, P., Stuart, B., Hobbs, F. D. R., Moore, M., Barnett, J., Popoola, D., ... & Yao, G.
(2015). An internet-delivered handwashing intervention to modify influenza-like
illness and respiratory infection transmission (PRIMIT): a primary care randomised
trial. The Lancet, 386(10004), 1631-1639.
Mallet, C., Eschalier, A., & Daulhac, L. (2017). Paracetamol: Update on its Analgesic
Mechanism of Action. In Pain Relief-From Analgesics to Alternative Therapies.
InTech.
Mok, W. Q., Wang, W., & Liaw, S. Y. (2015). Vital signs monitoring to detect patient
deterioration: An integrative literature review. International journal of nursing
practice, 21(S2), 91-98.
Nishimura, M. (2015). High-flow nasal cannula oxygen therapy in adults. Journal of
intensive care, 3(1), 15.
Ong, J. J. Y., & De Felice, M. (2017). Migraine Treatment: Current Acute Medications and
Their Potential Mechanisms of Action. Neurotherapeutics, 1-17.
Stamp, K. D., Dunbar, S. B., Clark, P. C., Reilly, C. M., Gary, R. A., Higgins, M., & Ryan,
R. M. (2016). Family partner intervention influences self-care confidence and
treatment self-regulation in patients with heart failure. European Journal of
Cardiovascular Nursing, 15(5), 317-327.
Ussher, M. H., Taylor, A. H., & Faulkner, G. E. (2014). Exercise interventions for smoking
cessation. The Cochrane Library.
Varble, A., Albrecht, R. A., Backes, S., Crumiller, M., Bouvier, N. M., Sachs, D., & García-
Sastre, A. (2014). Influenza A virus transmission bottlenecks are defined by infection
route and recipient host. Cell host & microbe, 16(5), 691-700.
Wahlin, R. R., Lindström, V., Ponzer, S., & Vicente, V. (2018). Patients with head trauma: A
study on initial prehospital assessment and care. International emergency nursing, 36,
51-55.
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Yang, Z. F., Mok, C. K., Peiris, J. S., & Zhong, N. S. (2015). Human infection with a novel
avian influenza A (H5N6) virus. New England Journal of Medicine, 373(5), 487-489.
Rohsenow, D. J., Martin, R. A., Tidey, J. W., Colby, S. M., & Monti, P. M. (2017).
Treating smokers in substance treatment with contingent vouchers, nicotine replacement and
brief advice adapted for sobriety settings. Journal of substance abuse treatment, 72, 72-79.
Kropff, B., Petersilka, G., Flemmig, T., Ehmke, B., Heuft, G., & Schneider, G.
(2016). Success of a smoking cessation programme in smoking behaviour of chronic
periodontitis patients and identification of predictors of motivation for smoking cessation–A
pilot study. International journal of dental hygiene, 14(3), 168-177.
Blyth, C. C., Macartney, K. K., Hewagama, S., Senenayake, S., Friedman, N. D.,
Simpson, G., ... & Cheng, A. C. (2016). Influenza epidemiology, vaccine coverage and
vaccine effectiveness in children admitted to sentinel Australian hospitals in 2014: the
Influenza Complications Alert Network (FluCAN). Eurosurveillance, 21(30).
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