NUR250 Assessment 1 S1 2018: Patient Assessment and Care Planning

This report provides a detailed patient assessment and care plan for Jim, a 58-year-old homeless male presenting with influenza symptoms. Task 1 focuses on the initial assessment, covering airway, breathing, and body temperature, emphasizing the importance of regular monitoring for effective care. Task 2 presents a nursing care plan addressing key problems like the risk of infection spread, self-care deficit, fluid volume imbalance, acute pain, and hyperthermia, outlining specific nursing interventions and rationales. Task 3 discusses medication management, including the administration of oseltamivir, paracetamol, and the flu vaccine (Fluvax), highlighting the nurse's role in patient education, proper administration, and monitoring for adverse reactions. This assignment highlights the crucial aspects of nursing care in managing a vulnerable patient's health needs.

NUR250 Assessment 1 S1 2018
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Task 1: Patient assessment
For providing safe and effective care to the patient, patient assessment plays a pivotal role in nursing
care. It is the responsibility of the licensed nursing practitioner to record these assessments with
utmost competency in order to help the patient reach utmost health (Kotronoula et al., 2014).
Jim who is a 58 year old homeless male is presented to the emergency department with the
symptoms including dyspnea, myalgia, fatigue, malaise, rhinorrhea and headache and thus, Jim
would be assessed for:
1. Airway
2. Breathing pattern
3. Body temperature
Airway:
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 Absence of an effective airway clearance can be observed if the presence of runny nose or
“rhinorrhea” is seen
 It is also presented as alterations in the rate and depth of breathing
 Non productive persistent cough is present with the production of sputum
 An ineffective clearance of airway will lead to dyspnea and restlessness
An early and regular assessment of the airway will help in early nursing interventions making it
possible to achieve and maintain a patent airway for Jim and increasing patient compliance to the
treatment.
Breathing:
 An abnormal breathing pattern is evident with coughing and increased rate
 Presence of erythema and inflammation of the tonsils and pharynx
 Presence of wheezing
Assessing the breathing pattern aids in ruling out reasons which resulted in the deviation from
normal pattern. Recording and periodic checking of auscultation sounds will give a regular update
about the respiratory status and providing the symptomatic interventions required.
Body temperature: An increase in body temperature is noted as a result of infection and
electrolyte imbalances
 Presence of tachycardia and tachypnea
 Skin feels warm and flushed with dryness on the mucous membranes
Periodic temperature evaluation in Jim’s care has to be incorporated to make sure that the
hyperthermia doesn’t become an uncontrollable one and the vital signs are maintained
Jim is presented with all the mentioned signs and symptoms and an inability in keeping a record of it
by regular assessment will lead to failure in providing the proper initial care which will directly
worsen the symptoms, degrading the vital signs and lung condition which can be life threatening
(Brown et al., 2017).
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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, clickenter 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.
Re
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To prevent and control
the spread of
influenzawithin the
healthcare facility and
the community.
 Vaccination protocol against
influenza should be followed
 Patient should be isolated in a
single room
 Vulnerable people like children and
old age people are discouraged
from visiting
 Vaccination improves immunity
to a particular disease. Flu
vaccine helps in formation of
antibodies in about two weeks
after vaccination. The
developed immunity provides a
protection against the virus
(CDC, 2017).
 Regular checks showing marked
reduction in incidence rates of the
influenza in the community.
 Increased participation and
awareness about following a proper
hygiene and infection control
protocol is observed.
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 Use of personal protection
equipments both for the heath care
workers and the visitors
 Using masks and respirators
 The spread of infectious
pathogens from spreading to
other patients can be prevented
with the help of patient
isolation (Scott, 2014).
 Old age people and children
have a poor immunity and they
may acquire infectious diseases
easily and to prevent this
infection spread discouraging
their meeting with the patient
is advisable.
 Influenza being highly
contagious may lead to the may
lead to infection spread even if
a slight negligence is done on
the part of health care workers
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or visitors. The respirators have
been found 95% efficient in
blocking the aerosol particles of
size as small as 0.3microns
(Kristen, 2009).
Nursing problem: Self care deficit
Underlying cause or reason: influenza infection results in severe myalgia and weakness
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Make the patient accept
the needed amount of
dependence and provide
supervision until patient
is able to carry the skills
effectively
 Implement measures to promote
independence but intervene only
when the patient cannot function
himself.
 Checking the patient regularly and
give him ample time to perform the
task.
 Providing the patient with
nutritional supplements
 An appropriate level of
assistance in care can prevent
any injuries due to inability and
help in a positive reinforcement
of patients which would help in
reducing the stress and
frustrations (Berbiglia et al.,
2013)
 The weakness which has caused
the patient dependence can be
 Improvement in health of the
patient is noted
 He is able to perform several tasks
he was unable to do at the time he
got admitted to the ward.
 A positive attitude and a willing
towards following proper health
protocol is observed.
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 Pain relieving medications
overcome by providing the
patient with required
supplements.
 The myalgia and distress which
rendered the patient in a
condition where he can’t
perform the regular tasks is
relieved by administrating of
certain medications like
analgesics and muscle relaxants
(Richard et al., 2011).
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason:
Dehydration due to fever
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Maintaining the adequate
fluid volume
 Providing regular fluid intake
 Administer electrolytes
 The primary rationale for fluid
resuscitation is to provide
proper tissue perfusion without
causing any harm to the patient
 Improvement in overall health
condition of the patient is noted
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(Ince, 2014).
 Maintenance of adequate fluid
volume provides an effective
blood circulation to the vital
organs of the body (Padhi et al.,
2013).
 The dull and flaky appearance of
skin shows improvements and
mucous membrane becomes moist.
Nursing problem: acute pain
Underlying cause or reason:
Persistent cough, fever and inflammation
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To provide relief from
pain and the discomfort
caused
 Assessing the pain in different parts
of body such as sore throat,
headaches and myalgia
 Monitoring the vital signs
 Analgesics administration (may
include acetaminophen.
Paracetamol)
 The presence of fever and
inflammation causes pain and
discomfort.
 Elevated vital signs are evident
in response to pain (Arbour and
Gélinas, 2010).
 The analgesics inhibit
 The decrease in pain which will
show marked reduction in anxiety
and distress.
 Reduced irritability and increased
social interactions
 Postural changes from guarded to a
relaxed one are noted
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 Use of massage and relaxation
techniques
prostaglandin synthesis which is
responsible for the pain
sensation thereby, reducing the
pain
 Such non pharmacological
approach makes the patient
focus less on pain and also
decreases muscular tension
(Dinarell et al., 2012).
Nursing problem: hyperthermia
Underlying cause or reason: exposure to the infection caused by virus
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To achieve and maintain
a normal body
temperature
 Monitoring the vital signs
periodically especially temperature
 Administration of antipyeretic
 The rise in temperature can be
attributed to the presence of
inflammatory process due to
infection. Regular monitoring
 Periodic evaluation suggestive of a
temperature change within the
normal range
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medicines
 Notifying doctor in case of
unresponsive temperature rise
helps in assessing the
effectiveness of medication and
an early detection of a rise in
temperature.
 A hypothalamic control can be
achieved using drugs like
antipyeretics under doctor
prescription to control the rise
in temperature
 The rise in temperature if not
controlled may lead to
permanent organ damage
(Eyers et al., 2010).
 Other vital signs show stability
 Changes in eating and sleeping
pattern is observed
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Task 3: Medication management
The clinical examination of signs and symptoms presented by Jim assisted in making a preliminary
diagnosis of influenza. For the relief in the emergency symptoms administration of 75mg of
oseltamivir has been started orally. Influenza is a disease of viral etiology and administration of
Oseltamivir which is an anti viral drug, is used in the treatment and prophylaxis of influenza. It has
been found that oseltamivir administration results in reduced pneumonia risk and reduced time for
first alleviation of symptoms is also noted (Jefferson et al., 2014).
Another drug administered to Jim is the Paracetamol which belongs to the NSAID group of drugs. It
being both the anti-inflammatory and analgesic drug will help Jim cope up with the myalgia and
headache and help relieving the inflammation in the airway making breathing easier. It reduces the
infiltration of the inflammatory cells into the aiway and thus reducing the pulmonary pathology
(Lauder et al., 2010). Jim is also given Fluvax which is a vaccine against influenza which will protect
him from any further infections.
Drug administration and monitoring to the patients under observation is the duty of the nursing
staff. Before administration of any drug, it is the duty of nurse to make the patient aware about the
medicine administered, its actions and potential side effects. It is the responsibility of the nurse to
administer the prescribed medicine through the proper route and on the proper time. While
medicine administration the nurse should ensure that the drugs and dosage are been prescribed by
the doctor and the patient is known to have no allergic reactions against them. Assessing and
recording the patient response to any medication should be done (NCBI, 2015).
Monitoring the adverse effects of the administered medicine is of prime importance and it can be
done by:
 Keeping a track on Jim’s vital signs before and after the intake of medicines
 Looking for any changes on skin or any other body reactions
 Monitoring any increase in severity of the symptoms
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