Medical Surgical Nursing 2 Assessment 1: NUR251, Semester 1, 2019

This report presents a nursing assessment and care plan for a 56-year-old male, Ian Haynes, admitted with acute kidney injury secondary to dehydration. The assessment includes a review of the patient's history, presenting problem, vital signs, urinalysis, and physical assessment findings. Task 1 focuses on nursing assessments, including fluid balance, cardiovascular status, and urinalysis interpretation. Task 2 outlines a comprehensive plan of nursing care, detailing interventions such as fluid management, dietary considerations, oral hygiene, and environmental modifications to address the patient's condition. The report emphasizes the importance of accurate assessment and timely interventions to prevent complications and promote patient recovery. The patient's history includes hypertension, type II diabetes, and osteoarthritis, which are considered in the development of the nursing care plan. The report highlights the significance of monitoring and adjusting care based on the patient's response and evolving clinical status. The report provides a detailed overview of the nursing care required for a patient with acute kidney injury, including assessment, planning, and implementation of interventions. The report emphasizes the importance of accurate assessment and timely interventions to prevent complications and promote patient recovery.

NUR251 Medical Surgical Nursing 2
Assessment 1 Semester 1 2019
Ian Haynes is a 56 year old male who has been admitted to hospital with acute kidney failure
secondary to dehydration.
History Assessment
Patient Ian Haynes, 56-year-old male from Adelaide currently working in
Darwin
Presenting problem Oliguria, nausea, lethargy and confusion
Presenting diagnosis Volume responsive Acute Kidney Injury secondary to dehydration
Background Mr Haynes had been concreting outside when he became ill with an
increasing headache followed by dizzy spells and nausea. He self-
administered Ibuprofen for symptoms with little effect. The following
day he collapsed at work and an ambulance was called to take him to
hospital. His work colleagues stated he had been irritable and confused
at times during the day preceding his collapse but felt it was related to
not coping with the Darwin heat and humidity. He also had not been
eating or drinking due to nausea and feeling unwell.
Mr Haynes was treated with IV fluids in the emergency department and
transferred to ICU for 48 hours to monitor his renal function.
He has now been transferred to a medical ward.
Phx Hypertension, Type II diabetes (diet controlled), mild osteoarthritis in
back, knees and hands
Medications  Perindopril 2 mg mane
 Ibuprofen 400mg PRN (OTC, self-medicates)
Diet/fluid intake Mainly diabetic, with occasional “treats”, drinks 5 – 8 cups of coffee
daily and occasion fruit juice/diet soft drink if he is thirsty
Alcohol use Social drinker, 2 to 3 beers, 2 to 3 times per week
Tobacco use 5 – 10 cigarettes per week, usually when drinking alcohol
Drug use Prescription medications only
Home/personal
relationship
Married with 2 adult children, all living in Adelaide. Wife is arriving in
Darwin today after hearing of her husband’s hospitalisation.
Career/work Self-employed concreter
Education Completed year 10 prior to working in the family concreting business
Economic background Owns his own house and business, but states if he doesn’t work he
doesn’t get paid. Wife is not employed and does home duties.
Ethnic background Australian born to Greek immigrant parents
Language spoken First language Greek, but educated in Australia with good
understanding of English as a second language
Religion/spirituality Catholic, attends church at Easter and Christmas and special occasions
with a strong belief in God.
ADLs Independent.
IADLs Drives both car and truck. Independent with finances. Wife attends to
cooking, all housework and bookkeeping for their business.
Sleep States he sleeps well 5 – 7 hours per night
Health maintenance Visits a GP in Adelaide every few months for diabetic and blood
pressure review. He states he is very rarely ill.
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NUR251 Medical Surgical Nursing 2
Assessment 1 Semester 1 2019
After 2 days of oliguria Mr Haynes urine output has increased and he has been transferred to a
medical ward.
Below is the information you have been handed over as you commence your shift on the medical
ward.
Urinalysis
Specific gravity 1.030
pH 5.5
Leukocytes Neg
Blood Neg
Nitrite Neg
Ketones Neg
Bilirubin Neg
Urobilinogen Neg
Protein ++
Glucose +
Physical assessment
CNS  Alert and orientated
 GCS 15/15
 Lethargic, fatigued, tired
 Sometimes slow to respond
CVS  Nil oedema noted
 Peripheries warm and well perfused
 Serum urea and creatinine levels slightly elevated
 Regular pulse rate and rhythm
 No abnormalities detected on auscultation of heart
Respiratory  Shallow regular respirations
 Chest expansion symmetrical
 No abnormal breath sounds on auscultation
Skin  Skin intact
 Dry
 Slight pruritus to arms
Gastrointestinal  Loss of appetite and slight nausea
 Nil vomiting
 Regular bowel movements but slightly constipated
 Low potassium diabetic diet
 Protein restriction to 60g per day
Urinary  IDC insitu
 Output 40 – 80 mls per hour
 Strict hourly monitoring of input and output
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Vital signs
Temperature 36 degrees Celsius
Heart rate 95 beats per min
Respiratory rate 22 resps per min
Blood pressure 160/95mmHg
O2 saturations 94% on room air
Pain score 0-2 / 10

NUR251 Medical Surgical Nursing 2
Assessment 1 Semester 1 2019
 Fluid restriction 1 litre per day
 eGFR 59 mL/min/1.73m2
Charted medications:
 Ramipril 5mg mane oral
 Frusemide 20mg bd oral
 Paracetamol 1g PRN oral
 Ibuprofen 400mg PRN oral
Based on the information above, address the following tasks.
Task 1. Nursing Assessments
Fluid assessment
Fluid assessment is important to Mr . Hayden since it will indicate the level or
quantity of fluids in his body to indicate any abnormalities or nursing problem.According to
recent studies, 60% of the body weight is made up of water which is distributed in different
parts of the body.75% of the water is in the interstitium while 20% is in the plasma (Ahmed
& Bagshaw, 2016). Finally, 5% exist as transcellular fluids. Under normal conditions, the
level of water and electrolytes are maintained by a balanced intake and output. However,
certain conditions like acute kidney injury impairs the balance. Therefore, the goal of this
assessment in this case is to find out if there is balance or imbalance in the distribution of the
fluids in the body (Cerdá et al., 2017). Fluid assessment is done best through inquiring about
incontinence or measuring the amount of urine produced by Mr. Haysen. Incontinence is a
sign of fluid imbalance.
Cardiovascular assessment (blood pressure and pulse)
The goal of this assessment is to find out if the patient is hypovolemic or not.
According to recent studies, Mr. Haysen can be considered not to be hypovolemic if his
blood pressure is equal or more than 90 mm HG. Other notable features include absence of
orthostatic. The heart rate should also be between 60 and 100 beats per minute (Dépret et al.,
2019). This assessment is very important to Mr. Haysen. From the assessment, the respiratory
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NUR251 Medical Surgical Nursing 2
Assessment 1 Semester 1 2019
rate was 22 beats per minute which is below the normal 60 beats per minute.
The blood pressure on the other hand was 160/95mmHg which is higher than the normal
range of 120/80mmHg. He is suffering from acute kidney injury and risks excessive loss of
fluids (Ingelfinger, 2017). This assessment is therefore important since it provides blood
pressure measurements that can be used as the basis to determine if the patient has
hypovolemia or not.
The procedure for undertaking this assessment includes the use of an equipment
known as sphygmomanometer. A hand cuff is placed below the elbow and the hand should be
paced below the heart. The patient is then encouraged to relax since curiosity can alter the
validity of the results. The blood pressure and the pulse rate are then obtained.
Urinalysis
During urine assessment, it was positive for glucose and protein. This is not normal
and indicates kidney problems. Under normal conditions, the urine filters proteins and
substantial amount of glucose. Urobilinogen was also negative and this is not normal. Low or
absent urobilinogen might indicate blocked biliary system.The Acute kidney injury diseases
is a condition in which the kidneys suddenly lose their abilities to filter and excrete certain
components. It therefore leads to build up of chemical substances that may in return be
harmful to the body (Kaddourah, Basu, Bagshaw, & Goldstein, 2017).
In most cases, the amount of urine produced is low. This assessment is therefore
important in the case of Mr. Hayden since it will quantify the amount of urine he produces on
a daily basis and a comparison with the normal levels will be made to find out if he is
actually suffering from the condition or not.
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NUR251 Medical Surgical Nursing 2
Assessment 1 Semester 1 2019
This assessment can be done by the instructing the Mr. Haysen to
collect urine which is then quantified. In this case for example, it was noted that Mr. Haysen
produced 40-80 mls per hour. This low than the normal values of 2000 mls per 24 hours
(Kaddourah, Basu, Goldstein, & Sutherland, 2019). It is therefore important that the nurse
categorically and accurately conducts the above assessment so as to confirm the pathological
condition that Mr. Haysen is suffering from. Remember, wrong assessment leads to wrong
nursing intervention and eventually death.
Task 2. Plan and Implement Nursing care
Acute kidney injury alters the normal functioning of the kidneys such that they are not
able to absorb or retain electrolytes and fluids in the body. As the two components
excessively exist the body, a condition known as deficient fluid Volume (FVD) arises. In
older patients, this condition is likely to result to fluid imbalances. It is therefore important to
initiate appropriate management to prevent hypovolemic shock (Kellum, Bellomo, & Ronco,
2015). The ultimate objective of management is to treat the underlying condition so that the
extracellular fluid compartment and fluid volumes are restored back to normal so as to
eventually correct any potential electrolyte imbalances. Other goals and the expected
outcomes include: ability of Mr.Haysen to verbalize awareness of the risk factors and
behaviours necessary to prevent fluid deficit, ability of the patient to describe different signs
and symptoms necessary to consult a healthcare provider (Legrand & Darmon, 2015). The
other objective and expected outcome is that Mr.Haysen is able to demonstrate changes in
lifestyle that can avoid progression of dehydration.
The first nursing intervention in this case is to urge Mr. Haynes to drink the
prescribed amount of fluid by the doctor. It is usually prescribed in patients with mild fluid
deficit like in this case since it is also a cheap method for replacement therapy (Li,
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NUR251 Medical Surgical Nursing 2
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Burdmann, & Mehta, 2013). This nursing intervention is quite important to
Mr. Haysen who is 53 years old. According to studies, older adults or people like Haysens
have decreased sense of thirst. It is therefore important that they are constantly reminded to
take the necessary fluids as authorised by the doctor. However, both the nurse and the doctor
ought to be very creative in this case in the manner they select they select fluid sources. They
can therefore choose flavoured gelatin, frozen juices bars, sport drinks (Zoccali & Bolignano,
2016). Furthermore, the oral hydrating solutions such as Rehydrate can also be considered.
The importance of this nursing intervention in the long run is to facilitate fluid replacement in
Mr.Haysens.
Mr.Haysen should be assisted to eat especially by the nurse or other family members.
From the case study, Mr. Haysen was not eating and drinking properly due to nausea.
Besides, he was also weak. The importance or rather rationale of this nursing intervention
therefore is to ensure that the patient meets the recommended or the prescribed intake
independently (Macedo et al., 2018). This will also facilitate the manner or action of the
prescribed drugs.
The nurse should emphasize the importance of oral hygiene. Studies indicate that
fluid deficit results to dry and sticky mucous membranes of the mouth. The rationale or the
importance of this nursing interventions as proposed by studies is to promote interest in
drinking different fluids and this will lower the discomforts of the dry mucous membranes.
The nurse should place Mr. Haysen in a conducive or cool environment. This can be
achieved through the use of light sheets. From the case study, Mr. Haysen has already lost a
considerable amount of fluids as shown by his oliguric state and the urge to drink more water
(Maiwall, Sarin, & Moreau, 2015). Placing him in a place with excessive heat will contribute
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NUR251 Medical Surgical Nursing 2
Assessment 1 Semester 1 2019
to further loss of fluids. The importance of this nursing intervention is
therefore to minimize the extra loss of fluids due to overheating.
The nurse should insert IV catheter so as to access IV. In this case, Mr. Haysen is
experiencing hypovolemic conditions. The signs for hypovolemic shock are weakness,
confusion, fatigue, little pee, rapid heartbeats and shallow breathing. This nursing
intervention otherwise known as parenteral fluid replacement is to prevent the hypovolemic
complications in Mr. Haysen.
Administration of parenteral fluids as prescribed by the doctor is also an important
nursing intervention in this case. The nurse is supposed to consider the importance of IV fluid
challenge with sudden or rapid infusion of fluids in Mr.Haysen with abnormal vital signs like
the case of Mr. Haysen (Mehta et al., 2016). According to recent studies, normal hydration
status can only be maintained with the help of fluids. Therefore, this implies that the
importance of this nursing intervention is to maintain or sustain hydration status in the
patient. However, the nurse is supposed determine the type and quantity of fluids for
infusion. This can be determined by the different clinical status.
In case there are signs of fluid overload, the nurse is to refer to the doctor
immediately. The importance of this nursing intervention is to maintain or sustain
Intravenous flow rates (Pettilä & Bellomo, 2014). This is according to findings in recent
studies which state that elderly patients like Mr. Haysen are susceptible to fluid overload.
This therefore the need for immediate attention.
The nurse should assist Mr.Haysen in planning activity when he has the energy.The
aim or objective of this intervention is that it will assist Mr.Haysen in planning patient centre
care outcome (Schneider & Bellomo, 2013).
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The nurse should also assist Mr. Haysen to verbalize needs .The
rationale for this intervention is that feelings of anxiety will reduce and this will provide
room for communication (Pettilä & Bellomo, 2014).
The nurses can teach Mr. Haysen energy conservation techniques like sitting to do
tasks. This will generally assist Mr. Haysen to lower the rate of oxygen consumption, thus
allowing prolonged activities (Zoccali & Bolignano, 2016).
The nurse should consider interspersing activities periods with resting periods. This
will ensure that no myocardial stress (Schneider & Bellomo, 2013).
Administration of chartered medicines to Mr.Hysen is also important. Diuretics can
be administered to get rid of excess fluids that cause inflammation. Anti-inflammatory drugs
can also be used to prevent inflammation of kidneys. Calcium infusion can be used to restore
calcium levels (Pettilä & Bellomo, 2014). Finally,kionex can be prescribed to prevent
accumulation of potassium in blood.
Patient education is also an important nursing intervention. Mr.Haysen together with
his family members should be taught on how to monitor certain vitals at home. Such vitals
include blood sugar and blood pressure and the urine output (Zoccali & Bolignano, 2016).
The importance of this intervention is to act as an indicator of the fluid status. Education on
proper nutrition is also an intervention. This is important since it increases the patient’s
knowledge and this will eventually assist in the prevention and management of imbalanced
fluid intake.
Task 3. Patient education
Before a patient is discharged, studies propose patient education which can be used to
prevent reoccurrence of the same condition. In the case of acute kidney injury that Mr.
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NUR251 Medical Surgical Nursing 2
Assessment 1 Semester 1 2019
Haysen is suffering from, he should be educated on the relevance or
importance of proper nutrition and hydration. The management strategies I can employ in this
case is provide a schedule on how he should drink more fluids (Shi & Wang, 2016). The
patients should be told not to eat foods that have high sodium, potassium, phosphorus and
protein. This is because studies link this components to increased acute kidney injuries.
Besides, the patient should also be educated on how to keep a record of everything that he
drinks or eats. This can assist the doctor to understand any underlying risk factors.
Mr.Hayden should also be taught on the importance of recording the quantity of urine
and stool he has each day. According to recent studies, oliguria and little pee per day
indicates potential fluid volume imbalances (Shi & Wang, 2016). Therefore, instructing the
patient to make these records will enable the doctor and the nurse assess the progress after the
nursing intervention. The management strategies can be done by providing a diary or chart
that the patient can indicate on a daily basis. In case a catheter is inserted, the patient should
be educated on good hygiene practices. This education is important since good hygiene
practices prevent bacterial infection around the catheter.
Mr. Haysen should also be taught on how to manage other health conditions. Studies
indicate that the risk factors for acute kidney injury include diabetes, hypertension and
cardiovascular diseases. The patient should therefore be educated on the importance of
medication for the above conditions. Mr. Haysen should also monitor his blood pressure and
blood sugar levels. In case the values are not normal, the patient should be instructed to seek
medical attention immediately.
Haysen should be warned not to take any over the counter medicines without the
consent of the physician. Recent studies indicate that certain medicines increase the risk of
kidney damage. They include the NSAIDS, stomach medicine and laxatives. The patient
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should therefore follow instructions on the packages and should stick to the
prescribed dosage. This will eventually reduce the risk of acute kidney Injury. Other patient
management education to the patient include daily measurements of weight. This should be
done with the same clothes, same time of the day (Zoccali & Bolignano, 2016). The patient
should then keep records. This is important since weight loss is a sign of acute kidney injury.
In case the patients notes a drop in the weight, he should be instructed to report back to the
physician.
Finally, Mr.Haysen will be instructed to come back as a follow up activity. This is
important since it will give the nurse and physician to assess the progress of the nursing
intervention. The patient can then be referred to a kidney specialist for special care. The
ultimate desire is that the patient stays free from the acute kidney injury condition.
References
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Assessment 1 Semester 1 2019
Ahmed, M., & Bagshaw, S. M. (2016). Management of oliguria and acute kidney injury
in the critically ill. Oxford Medicine Online.
doi:10.1093/med/9780199600830.003.0213
Cerdá, J., Mohan, S., Garcia-Garcia, G., Jha, V., Samavedam, S., Gowrishankar, S., …
Mehta, R. (2017). Acute Kidney Injury Recognition in Low- and Middle-Income
Countries. Kidney International Reports, 2(4), 530-543.
doi:10.1016/j.ekir.2017.04.009
Dépret, F., Peacock, W. F., Liu, K. D., Rafique, Z., Rossignol, P., & Legrand, M. (2019).
Management of hyperkalemia in the acutely ill patient. Annals of Intensive Care,
9(1). doi:10.1186/s13613-019-0509-8
Ingelfinger, J. R. (2017). Acute Kidney Injury in Critically Ill Children — An Ominous
Legacy. New England Journal of Medicine, 376(1), 82-83.
doi:10.1056/nejme1613456
Kaddourah, A., Basu, R. K., Bagshaw, S. M., & Goldstein, S. L. (2017). Epidemiology of
Acute Kidney Injury in Critically Ill Children and Young Adults. New England
Journal of Medicine, 376(1), 11-20. doi:10.1056/nejmoa1611391
Kaddourah, A., Basu, R. K., Goldstein, S. L., & Sutherland, S. M. (2019). Oliguria and
Acute Kidney Injury in Critically Ill Children. Pediatric Critical Care Medicine,
1. doi:10.1097/pcc.0000000000001866
Kellum, J. A., Bellomo, R., & Ronco, C. (2015). Does this patient have acute kidney
injury? An AKI checklist. Intensive Care Medicine, 42(1), 96-99.
doi:10.1007/s00134-015-4026-4
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Assessment 1 Semester 1 2019
Legrand, M. M., & Darmon, M. (2015). Renal Imaging in Acute Kidney Injury. Acute
Nephrology for the Critical Care Physician, 125-138. doi:10.1007/978-3-319-
17389-4_10
Li, P. K., Burdmann, E. A., & Mehta, R. L. (2013). Acute kidney injury: Global health
alert. Hong Kong Journal of Nephrology, 15(1), 1-5.
doi:10.1016/j.hkjn.2013.03.001
Macedo, E., Cerdá, J., Hingorani, S., Hou, J., Bagga, A., Burdmann, E. A., … Mehta
L., R. (2018). Recognition and management of acute kidney injury in children:
The ISN 0by25 Global Snapshot study. PLOS ONE, 13(5), e0196586.
doi:10.1371/journal.pone.0196586
Maiwall, R., Sarin, S. K., & Moreau, R. (2015). Acute kidney injury in acute on chronic
liver failure. Hepatology International, 10(2), 245-257. doi:10.1007/s12072-015-
9652-y
Mehta, R. L., Burdmann, E. A., Cerdá, J., Feehally, J., Finkelstein, F., García-García, G.,
… Remuzzi, G. (2016). Recognition and management of acute kidney injury in
the International Society of Nephrology 0by25 Global Snapshot: a multinational
cross-sectional study. The Lancet, 387(10032), 2017-2025. doi:10.1016/s0140-
6736(16)30240-9
Pettilä, V., & Bellomo, R. (2014). Understanding acute kidney injury in sepsis. Intensive
Care Medicine, 40(7), 1018-1020. doi:10.1007/s00134-014-3313-9
Schneider, A. G., & Bellomo, R. (2013). Acute kidney injury: new studies. Intensive
Care Medicine, 39(4), 569-571. doi:10.1007/s00134-013-2860-9
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