NURSING 4 Assignment: Clinical Features and Nursing Interventions

This comprehensive nursing assignment explores a wide range of medical conditions, including acute kidney injury, gastrointestinal disorders, ischemic stroke, complex regional pain syndrome, asthma, and many others. The assignment delves into the clinical features of each condition, providing a clear understanding of how they manifest. Furthermore, it outlines essential nursing interventions for effective patient care, covering aspects such as assessment, planning, and evaluation within a surgical nursing framework. The assignment also addresses holistic nursing care, focusing on the patient's overall well-being, and discusses specific procedures like prostatectomy, cataract extraction, and the management of internal bleeding. Additional topics include parenteral nutrition, monitoring patient responses to treatment, PICC line care, pain management techniques, assessing levels of consciousness, respiratory and cardiac arrest, pneumonia, deep vein thrombosis, acute pancreatitis, tracheostomy suctioning, and interventions for impaired gas exchange. The assignment also covers the management of intercostal catheters, BPAP and CPAP, pulse oximetry, defibrillators, burn classifications, venous thromboembolism, fracture causes and types, and greenstick fractures, providing a complete overview of crucial nursing concepts and practices.

Running Head: NURSING
NURSING
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Question one
a) Acute kidney injury occurs when there is a sudden damage to the kidney. It is also called
acute kidney failure. AKI is reversible if it is discovered and treated at its onset. The two
clinical features of AKI include fatigue and shortness of breath
b) Acute gastrointestinal disorders include conditions such as constipation, anal fissures,
anal fistulas, colon polyps and colitis among others. Clinical features of acute
gastrointestinal disorders include; pain in the belly and constipation.
c) Ischemic stroke occurs when the body is not supplying blood to the brain. Ischemic
stroke develops when the arteries around the brain block hence failing to supply blood.
Ischemic stroke is caused by atherosclerosis. The clinical features include sudden trouble
in walking and trouble in speaking (Bullock & Manias, 2011).
d) Complex regional pain syndrome is a condition that affects one limb after injury. The
clinical features for Complex regional pain syndrome include motor and trophic
abnormalities.
e) Asthma refers to a condition in which the airways in an individual swell and produce
mucus. The clinical features evident in Asthma include shortness of breath and chest pain
(Lewis, Dirksen, Heitkemper, & Bucher, 2014).
f) This is a situation that occurs when a person becomes unable to stimuli and appears to be
unconscious for some time. The clinical features of acute unconscious state include drug
overdose and adverse loss of blood.
g) Angina Pectoris is the discomfort that is caused by the coronary heart disease. The
clinical features of Angina Pectoris include sweating and dizziness.

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h) Cellulitis is a serious skin infection whereby the affected skin appears swollen and
painful to touch. The clinical features include tight swollen skin and fever.
i) Dehydration refers to a condition that happens when body fluids exceed the amount that
is taken in the body. The clinical features here include thirst and headache
j) Hemorrhagic Shock is a type of shock that leads to insufficient delivery of oxygen at the
cellular level. Clinical features here include chest pain and anxiety (Tollefson, Bishop,
Jelly, Watson, & Tambree, 2012).
k) Concussion is a type of brain injury that occurs after an impact to the head. The clinical
features for v include vomiting and a feeling of pressure in the head.
l) Myocardial infarction is a condition that occurs when there is a decrease in blood flow or
when the blood stops in a part of the heart therefore causing damage to the heart. Clinical
features of Myocardial infarction include cough and Nausea.
m) Nephrolithiasis is a calculi in the kidneys. The clinical feature here include adverse pain
in the back and Dizziness (Crisp & Taylor, 2012)
n) Bacterial Sepsis is a condition that occurs when the response of a body to an infection
leads to an injury of the body tissues and organs. The clinical features of this sickness
include fever and increased rate of breathing.
Question 2
Principles of surgical nursing
1. Assessment, planning and evaluation of nursing framework
2. Managing nutrition
3. Managing pain

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4. Managing infection control
5. Managing wound
6. Managing stress and anxiety (Estes, Calleja, Theobald, & Harvey, 2015)
7. Managing altered body change
8. Managing fluid balance
B)
k) Prostatectomy is the surgical procedure performed for the partial or total removal
of the prodtrate.it is done to treat prostrate cancer.it involves removal of the prostate
glands.
l) Cataract extraction refers to the surgical procedure that is done to remove lens in the
eye that has become blurred or cloudy over time hence affecting the ability of a person to
see. The latter is replaced with other clear lens called intraocular lens (Brotto & Rafferty,
2016).
m) Internal bleeding due to trauma is a condition that may happen after a significant
physical injury. There exist two types of trauma; blunt trauma and penetrating trauma.
Both of these kinds of trauma can lead to internal bleeding.
Question 3
Holistic nursing care is a nursing care that focuses on the promotion of wellness
though the removal of physical suffering and healing of the complete person. Holistic
care is much more concerned with wellness more than illness.it is significant since it
considers body, spirit, mind, the environment and the community as a whole (Clarke,
Gray, White, Duncan, & Baulme, 2016).

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Question 4
Too Too Wadadi received holistic care because his operation happened in a maximum six
hours. There were no delays that could lead to irreversible that cause anemia. The resources
where available hence the shifting other patient from one department to another did not
consumer time that could contribute to poor outcomes (Martini, Nath, Bartholomew, & Ober,
2017).
5b) Total Parenteral Nutrition refers to the feeding of specialist nutritional products in an
intravenous manger bypassing the usual process of eating and digesting. The three indications for
parenteral nutrition include bowel obstruction, prolonged fistula and severe malnutrition.
A TPN component is typically composed of water, proteins, lipids, carbohydrates and vitamins
and minerals.
Question 6
It allows for the patient to respond to the treatment so that evaluation can take place. The
common parameters in this matter include temperature, blood pressure, respiratory rate, and the
quantity of urine output, the peripheral saturation of oxygen and pain scores (Australian Nursing
& Midwifery Council, 2012).
Question 7
Two functions of peripherally inserted central catheter include; it can be used for long
chemotherapy regimens or can also be used in the administration of substances that could be
done peripherally. PICC is associated with accidental withdrawal and occlusions.

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When an infection for PICC is assumed, send the catheter tip to the lab so that it can be cultured.
Place the gauze over the insertion site along with an occlusive dressing for at least 24 hours and
then change as required. Caring for PICC after treatment is vital since it keeps them working
longer and reduces infection and hence improving the safety and comfort of the patient
(Sorrentino & Remmert, 2019).
Question 8
The pain control analgesia PCA treatments include patient controlled pump which safety
allows the patient to push and deliver trivial portions of pain medicine into the intravenous line.
The patient controlled Epidural Analgesia which uses a pump to convey pain regulator drug into
epidural catheter. The nerve block can also be used in pain management. The nerve block
controls pain which is secluded to a smaller area of the body.
Question 9
a) Assessing the level of patient’s consciousness can be done by using AVPU scale whereby
the patient is alerted, told to respond to voice, pain and unconsciousness.
b) The signs and symptoms that one needs to monitors include stupor as a result of decreased
pain perfusion and arrest due to unresponsive flaccid tonic posturing.
Question 10

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(Australian Nursing &
Midwifery Council, 2012).
Question 11
During the process of respiratory arrest, breathing is halted. All through cardiac arrest,
blood flow stops .cardiac arrest is where the heart is not beating and it is evaluated by the fact
that the blood flow is no lengthier noticeable though the heart is beating respiratory arrest leads
to cardiac arrest if nothing is done to it. When a person is suffering from respiratory arrest, CO2
is removed from the bloodflow leading to build up of carbonic acid the superfluous acid can
cause heart problems and cause cardiac arrest (Brotto & Rafferty, 2016).

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Question 12
a) Pneumonia
b) Deconditioning
c) Muscle weakness
d) Secondary pressure areas
b) When treat DVT at home, it is good to; wear graduated compression stockings, elevate
the affected legs and take walks (Bullock & Manias, 2011).
Question 13
The clinical manifestation of Acute Pancreatitis includes; fever, biliousness and
queasiness, distended and gentle abdomen and superior abdominal discomfort.
complex nursing interventions of Acute Pancreatitis include; maintenance of skin care, keeping
the milieu free of food smells, promoting position comfort, maintaining bed rest during the acute
attack and investigating verbal reports of pin and giving the specific location of intensity
(Bullock & Manias, 2011).

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Question 14
a). Indications of tracheostomy suctioning
Signs of respiratory distress
Vomiting
Desaturation on pulse oximetry
b). Nursing management in tracheostomy suctioning involves covering the thumb hole
for 10 seconds maximum, slowly taking the catheter out of trach tub by twisting it amid
the thumb and middle finger and suctioning the trach more than one time. Finally, suction
the patient’s mouth and nose with the catheter.do not return the catheter back to the trach
tube after use (Crisp & Taylor, 2012).
Question 15
Nursing intervention for Ineffectual airway approval related to pneumonia and
Optimal positioning
Use of pillow
Use of abdominal muscles
Use of huff techniques
Nursing intervention for impaired gas exchange related to acute and chronic lung disease
Restoration of ventilation so that CO2 can be released from the body. The latter includes non-
invasive ventilation that would provide ventilator support via upper airways (Sorrentino &
Remmert, 2019). Mechanical ventilation can also be a cure whereby a special tubule is inserted
through the mouth then into the airway

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Nursing intervention for Risk for compromised impulsive aeration related to loss of hypoxemic
respiratory drive and respiratory muscle exhaustion. (Lewis, Dirksen, Heitkemper, & Bucher,
2014).
Administration of antibiotics, inhaled or oral corticosteroids and bronchodilators.
Question 16
Nursing management of a patient with an intercostal catheter and an underwater chest drainage
tube
Keep all tubing free of occlusions for instance; check the tuning beneath the patient of amid bed
rails.
Take time to check the fluid filled loops
Keep the CDU below the patient’s chest.
Do not clamp the test tube for chest tube care
After every two hours, document a comprehensive assessment including the respiratory rate and
work of breathing and breathing sounds (Martini, Nath, Bartholomew, & Ober, 2017).
Question 17
BPAP and CPAP are good machines for the treatment of patients suffering from sleep
apnea. They allow the patient to breathe easily and regularly throughout the night. Nurses can
manage the patients with breathing difficulties by using BPAP and CPAP. The machines are
used for the patients with increased pressure strengths and where exhaling against incoming air
becomes difficult as if the patients are forcing the air out (Lewis, Dirksen, Heitkemper, &
Bucher, 2014).

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Question 18
Pulse oximetry checks how well a patient’s heart is pumping oxygenated blood
throughout the body. It is used to monitor the heat of the patients with any type of condition that
affects the level of oxygenated blood in the body (Crisp & Taylor, 2012).
Defibrillator is used to detection and stoppage of abnormal heartbeats. The device is used to
monitor heartbeat and deliver electrical impulse so as to restore a normal heart rhythm when
necessary.
Question 19
Classification of burns based on causative factors
First degree-this is the type of burn that affects only the external layer of the skin. The burn
region is red
Second degree-this is the type of burn that involves the epidermis and the lower stratum of the
skin. The burn region seems swollen and it is agonizing (Tollefson, Bishop, Jelly, Watson, &
Tambree, 2012).
Third degree –is a burn that destroys both the dermis and epidermis. The burn region looks white
or blackened
Fourth degree-this is whereby the burn goes via the two layers of the skin and
The classification is done according to how severely they penetrate the surface of the skin and
the underlying tissues and also in the deeper issues.
Question 20
Venous thromboembolism refers to a disease that includes deep vein thrombosis and
pulmonary embolism. Both DVT and PE are forms of VTE. There are two types of VTE
including; deep vein thrombosis (DVT0 and Pulmonary Embolism (PE).The clinical features of

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DVT include swelling on your feet or legs on one side and severe pain in the foot or ankle. The
clinical features for PE include a sudden onset of dyspnea and chest pains (Brotto & Rafferty,
2016).
Question 21
Extrinsic causes of fractures
Indirect violence
Bending forces
Shearing forces
Intrinsic Causes of Fractures
Fractures due to muscular action
Pathological fractures (Brotto & Rafferty, 2016).
Green stick fracture refers to a fracture in a young and soft bend bones and breaks. Greenstick
fracture occurs to children who are ten years and below.
Clinical features of greenstick fracture vary depending on the severity of the fracture. Mild
fractures may be mistaken for sprains or bruises. The symptoms include development of bruises,
general tenderness in the mild structures and bending of the fractured area.

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References
Australian Nursing & Midwifery Council. (2012). National competency standards for the
enrolled Nurse. Melbourne: AUSW.
Brotto, V., & Rafferty, K. (2016). Clinical dosage calculations. 2nd ed. Syndey: Cengage.
Bullock, S., & Manias, E. (2011). Fundamentals of Pharmacology . Sydney: Pearson
Publications.
Clarke, L., Gray, S., White, L., Duncan, G., & Baulme, W. (2016). Foundations of
nursin:Enrolled Division 2 Nurses. 3rd ed. Sydney: Cengage.
Crisp, J., & Taylor, C. (2012). Potter & Perry’s fundamentals of nursing (4th Australian Ed.).
Chatswood, NSW: Mosby Elsevier.
Estes, M., Calleja, P., Theobald, K., & Harvey, T. (2015). Health assessment and physical
examination. 2nd ed. Sydney: Cengage.
Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical surgical nursing:
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Martini, F., Nath, J., Bartholomew, E., & Ober, W. (2017). Fundamentals of anatomy &
physiology. 11th ed. London: Pearson.

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Sorrentino, S. A., & Remmert, L. N. (2019). Mosby’s Textbook for Nursing Assistants: Safely
Transferring the Person. Melbourne: Pearson.
Tollefson, J., Bishop, T., Jelly, E., Watson, G., & Tambree, K. (2012). Clinical
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