Medical Surgical Nursing Tasks 1-5: Patient Assessment and Care

This document presents a comprehensive nursing assignment addressing the care of a patient, Jim, diagnosed with influenza. It encompasses five key tasks: patient assessment, care planning, medication management, patient teaching, and clinical judgment. The patient assessment focuses on identifying hypertension, breathing insufficiency, and potential infection. The care plan addresses nursing problems like the risk of infection spread, self-care deficits, imbalanced fluid volume, constipation, and activity intolerance, with detailed interventions and rationales. Medication management includes the use of Oseltamivir, Paracetamol, and Fluvax, with a focus on monitoring side effects and patient education regarding medication administration and potential adverse reactions. Patient teaching emphasizes infection control measures and recognizing signs and symptoms. Finally, clinical judgment examines the physiological effects of the illness and the need for interventions like supplemental oxygen. This assignment provides a complete overview of the nursing care required for a patient with influenza.

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NUR250 Medical Surgical Nursing
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Task 1: Patient assessment
Jim need to be assessed for hypertension, breathing insufficiency and infection. It is required
to assess blood pressure in Jim because provided data indicates he is exhibiting hypertension.
According to provided handover his blood pressure is 158/86 mmHg. Blood pressure
assessment can be done by measuring blood pressure by using sphygmomanometer. Blood
pressure measurement need to be done at rest position and after activity. Blood pressure
measurement need to be performed in lying position and standing position. Assessment of
infection can be done by performing WBC count because in infection there can be raised
WBC count. In assessment of other types of infections, differential count can be useful
however, in influenza differential count cannot give accurate assessment. Assessment of
infection can be performed by culturing sputum samples for the presence of influenza virus.
Assessment for insufficient breathing need to be performed in Jim. Insufficient breathing can
be performed by estimating respiratory rate and measuring oxygen saturation (Dewit et al.,
2016).
Assessment of infection is necessary in Jim because based on severity and type of infection,
nursing intervention can be planned for Jim. Accurate antibiotic need to be given to Jim
because infection can be controlled by specific antibiotic only. Uncontrolled infection can
exaggerate the condition in John because it lead to insufficient breathing and hypertension.
Infection of nasal cavity can lead to inflammation and edema in the nasal cavity. It can
interfere with breathing pattern which can lead to lowered oxygen saturation. Lowered
oxygen saturation level can force heart to pump forcibly which can lead to hypertension. All
these conditions are interrelated and can influence each other. Hence, these conditions need
to be assessed in Jim because it can affect physical, physiological and psychological
wellbeing of Jim (Berman, et al., 2014).
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Task 2: Care planning
Nursing Care Plan: Jim
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.
Assess risk of infection by culturing
sputum samples.
Perform WBC counting.
Encourage patient to wear mask during
coughing and sneezing.
Educate patient about maintaining hygienic
condition including washing hands with the
antiseptic solution. Decontaminate
accessories used by the patient.
Encourage patient to wear gown and
gloves.
Keep patient in the isolated environment
and Prevent patient to go to the places until
infection persists.
Assessment of risk of infection can be
helpful in planning early intervention
(Carpenito, 2013).
In infection there can be increased
WBC counting (Lemone et al., 2017)
Wearing mask can be helpful in
reducing risk of direct spread of
infection (Li et al., 2014)
Maintaining hand hygiene and
decontaminating accessories can be
helpful in reducing indirect spread of
infection (Patel et al., 2014; Manfredi
and D'Onofrio, 2013).
It can be helpful in preventing infection
(Patel et al., 2014; Manfredi and
D'Onofrio, 2013).
Absence of virus in the sputum sample.
Absence of symptoms related to infection.
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Administer suitable antibiotic after
consultation with physician.
Isolation of patient can be helpful in
preventing spread of infection from one
person to another (Patel et al., 2014;
Manfredi and D'Onofrio, 2013)
Administration of antibiotic can be
helpful preventing infection in the early
stage, hence its spread can be prevented
(Patel et al., 2014; Manfredi and
D'Onofrio, 2013).
Nursing problem: Self care deficit
Underlying cause or reason: Fatigue due to dyspnoea
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To encourage Jim to
perform activities of
daily living like
bathing, clothing,
eating etc.
Assess capability of Jim to preform
activities of daily living.
Provide walker or support whenever Jim
wishes to walk.
Provide assistance to Jim to perform his
activities.
Provide independent surrounding for Jim,
hence he can perform his activities without
hesitation.
Encourage Jim to perform activities at his
will.
Encourage participation of family members
Assessment can be helpful in planning
early intervention to improve his
activity level (Gulanick and and Myers,
2016).
Restricted assistance to patient can be
helpful to become self-sufficient (Seed
and Torkelson, 2012).
It can be helpful in improving self-
esteem and dignity of the patient (Seed
and Torkelson, 2012).
Jim is performing activities with the
minimal assistance.
Jim is performing activities of daily living,
cleaning teeth, taking bath and clothing.
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involvement to assist in his activities.
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: Inadequate and un-scheduled diet and fluid intake. Loss fluid due to vomiting as a result of consumption of medicianes.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To maintain sufficient
hydration in the patient.
Incorporate dietician in his care to maintain
input and output chart of Jim.
Assess body weight on daily basis.
Assess vital signs like blood pressure,
respiratory rate, heart rate and temperature
on regular basis.
Assess oral mucosa and skin turgor for
dryness.
Assess activity level and orientation of
patient using Glasgow coma scale.
It can be helpful to assess exact
requirement of fluid (McGloin, 2015).
Abnormalities in vital signs reflects
symptoms like tachypnoea, hypotension
and tachycardia indicate inadequate
consumption of fluid and risk of
dehydration (McGloin, 2015).
Dryness of oral mucosa and skin turgor
indicates dehydration in the patient
(McGloin, 2015).
Deficiency in electrolyte can lead to
reduced activity level and altered
orientation (McGloin, 2015).
Jim is consuming adequate amount of fluid
with respect to requirements of the body.
Normal oral mucosa and no signs of skin
turgor.
Nursing problem: Risk of constipation
Underlying cause or reason: Inadequate consumption of solid diet and liquid fluid.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Confirm that Jim get
respite from distress
Assess the stool consistency, also
determine frequency of defecation.
It can be helpful in the assessment of
abnormality during defecation in Jim
Normal defecation process in Jim.
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during defecation
Ensure Jim is drinking warm water in the
moerning.
Ensure Jim is consuming nutritious diet
and monitor diet consumption.
Prescribe bulk laxative on consultation
with physician.
Incorporate dietician and nutritionist in his
care.
(Costilla and Foxx-Orenstein, 2014).
It will be helpful in ensuring normal
and natural defecation in Jim (Costilla
and Foxx-Orenstein, 2014).
Laxatives can be helpful in relieving
constipation problem and maintaining
natural elimination (Costilla and Foxx-
Orenstein, 2014).
Adequate amount of fluid intake can be
helpful in softening the stool
consistency and improving stool
consistency (Costilla and Foxx-
Orenstein, 2014).
Jim has eliminated normal and well-formed
stools.
Jim mentioned that there is no distress
during defecation.
Nursing problem: Activity intolerance
Underlying cause or reason: Weakness and fatigue due to dyspnea
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
Ensure Jim is
performing activities of
daily living normally
and reduces risk of
respiratory
insufficiency.
Asses vital signs before and after
completion of activities and record
alterations in vital signs due to activity.
Extend support to Jim to perform activities
of daily living.
It can be helpful is assessing the early
signs of deterioration of the patient
(Doenges et al., 2016; Yates et al.,
2014)
It can be helpful in completion of
patient’s activities and reduce stress on
Jim can perform daily activities with ease
without breathing insufficiency.
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Encourage patient to take frequent rest
periods between the activities.
Consult with physician and provide
artificial oxygen to the patient.
Provide emotional support to the patient to
keep high moral to perform activities.
the patient. It can also be useful in
reducing risk of fall in the patient
(Doenges et al., 2016; Yates et al.,
2014)
Adequate rest can restore energy and
reduces risk of fatigue (Doenges et al.,
2016; Yates et al., 2014)
Improve breathing rate and breathing
pattern and reduces risk of fatigue
(Bailey et al., 2012)
It can be helpful in improving self-
confidence for activity tolerance after
cure from the disease (Potter et al.,
2013)
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Task 3: Medication management
Oseltamivir is an antiviral agent which can be useful against both Influenza A and Influenza
B virus. It is recommended to administer in first 48 hours of infection. Nurse need to monitor
symptoms of influenza in Jim. These symptoms include sudden onset of fever, cough,
headache, fatigue, muscular weakness and sore throat. If these symptoms not improved after
the administration of oseltamivir, nurse need to consult physician for the administration of
supplementary medications for the management of influenza symptoms. It is also associated
with psychological side effects hence nurse need to monitor behavioural and psychological
alterations in Jim (Tiziani, 2013).
Paracetamol is useful in treating pain and fever. From the provided data, it is evident that Jim
is associated with fever. Nurse need to monitor temperature in Jim on regular basis after
administration of paracetamol. Consumption of other medication containing paracetamol by
Jim also need to be monitored. If fever persists for more than three days after administration
of paracetamol, nurse need to consult physician. Nurse should make sure that Jim consuming
paracetamol after taking food because paracetamol should not be consumed on the empty
stomach. Paracetamol is prone to produce liver damage. Hence, nurse to perform liver
function test prior to and after administration of paracetamol in Jim (Tiziani, 2013).
Fluvax is the medication useful to control influenza infection. Fluvax can also be used as
preventive medicine because it can be used every year to prevent influenza infection. Fluvax
vaccine can produce antibodies in the body for 6 – 10 months. Nurse need to assess Jim for
anaphylactic hypersensitivity to egg and other components of vaccine because it is evident
that fluvax is prone to develop allergic reaction (Tiziani, 2013).
Task 4: Patient teaching:
Influenza virus can be contaminated through direct and indirect contact. Hence, Jim should
not cough or sneeze near susceptible person. It can produce direct transfer of influenza virus.
Indirect transmission of influenza virus can be prevented by washing hands after sneezing
because it can transfer influenza virus through indirect transfer. Nurse can educate Jim about
signs and symptoms of influenza. Preventing and controlling the incidence of and spread of
influenza is important for Jim because prevention of spread can reduce number of admissions
of influenza patients to the hospital. Hence, Jim can receive adequate amount of treatment.
Moreover, prevention of its spread can also be helpful in preventing re-infection to Jim
(Morton and Fontaine, 2017). Nurse need to educate Jim regarding influenza infection and its
prevention strategies. Moreover, nurse should demonstrate him procedures to prevent spread
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of infection. There should be continuous monitoring of Jim for adherence to the spread
prevention strategy of influenza. For the prevention of spread of infection, Jim need to wash
his hands and his belongings on the regular basis with suitable antiseptic solution. He should
keep himself isolated during the duration infection. He should use mask during sneezing and
coughing. He should wear gloves and gowns during his stay in the hospital. If Jim
experiences symptoms of influenza infection, he should consult with the physician for further
course of action (Jardins and Burton, 2015; Beachey, 2018).
Task 5: Clinical judgement and handover
Respiratory tract impairment can occur in patients with influenza virus infection. In this case
also there is deterioration of the respiratory tract infection due to infection. Hence it affected
functioning of the lung and there is reduced gaseous exchange between the alveoli and
capillary interface. As a result, there is reduced oxygen saturation in Jim and reduced supply
of oxygen to different organs including heart (Blanco eta l., 2010). Due to reduced supply of
oxygen, heart starts pumping fast to compensate for the reduced oxygen supply. Hence, there
is increased heart beat in Jim. To compensate for the reduced oxygen supply, there can be
faster breathing in Jim. Hence, his respiratory rate is increased. There is also increase in the
temperature in Jim.
Jim need to be supplemented with the artificial oxygen to improve his breathing pattern and
breathing rate. Jim should be advised to keep calm because stress due to his health condition
can exaggerate his condition. He need to be taught with the slow and deep breathing which
can be helpful in managing insufficient breathing. Jim need to follow this slow breathing
technique. He should also be administered with medications for hypertension and fever.
Early actions can be helpful in the improvement in the vital signs like blood pressure,
respiratory rate, heart rate and control of body temperature. Impairment in these vital signs
can lead to multiple organ deterioration. Hence, these early interventions can be helpful in
preventing deterioration of these organs.
I am a nursing student in the medical-surgical ward. I am concerned about patient Jim.
Through the administration of medication, his influenza A infection has been reduced.
However, this morning he became restless. He was also experiencing shivering. On
assessment, he exhibited abnormal breathing and reduced response to speak. His observed
vital signs were temperature 39.6̊C, heart rate 125 bpm, respiratory rate 24 bpm, blood
pressure 124/79 mm/Hg and oxygen saturation 86 %. Careful monitoring of the patient is
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required. Physician’s team assessed the Jim’s condition and refereed to the High Dependency
Unit to provide BIPAP.
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