Medical Surgical Nursing
Nursing Care of a Patient in a medical surgical setting
Task 1: Patient Assessment
The assessment of patients is an essential skill in nursing care to provide adequate care, treatment to the patients and to identify specific patients needs to design focused nursing interventions. The nursing assessments for Rosie are:
The nurse is requires to check the common clinical observations like body temperature, blood pressure, pulse rate and respiration rate and observe the physical condition and cognitive state at during admission to ward (Oliver, 2012). This is important for the Rosie suffers from condition of hypertension and hypercholesteremia along with sensory deficits in left eye. It is also to make certain that there is no blockage in respiratory tract for air passage for a better respiratory function. This assessment is not sincerely conducted will not assure that Rosie is safe during admission from emergency department.
Another assessment is for balance and gait to understand the level of difficulty in walking and maintaining body balance. This is vital to Rosie care as she is suffering from fall and has a bilaterally knee condition thus, nursing care can develop exercise routine and can identify any neurological reason for the treatment plan. Without nursing assessment, delivery of proper patient care is not possible (Kalisch et al., 2012). The nursing assessment also requires conducting a fall risk assessment upon admission which requires examining the history of previous falls and identifying the risk factors that can lead to falls which include issues related to health and surrounding hazards like slippery floors, patient footwear, stairs, lighting etc. This nursing assessment is relevant to Rosie as there has been increased no. of falls due to weakness and fatigue reported in past months. This can help the nurse to arrange assistive mobility equipment like canes, walker as per the patient condition. If this assessment is not done properly it could lead to fractures and other abnormalities which affect the safety parameter for the patient in the ward.
Task 2: Care Planning
Nursing Care Plan: Rosie
| Nursing problem: Geriatric symptom – Falls and less mobility | ||||
| Underlying cause or reason:
Muscle Weakness, Fatigue, visual impairment, balance problem and gait disturbances, environmental hazards |
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| Goal of care | Nursing interventions/actions | Rationale | Indicators your plan is working | |
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To ensure Rosie is safe from falls and optimize safety in the ward and risk management
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˚ Help the patient by adjust the bed position lower.
˚ Risk Assessment ˚ Assist in balance improvement exercise ˚ Reduction of environmental hazards ˚ Monitor medications
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˚ The lower bed position reduces the risk of serious injury due to fall (Kalisch et al., 2012).
˚ To document what extra precautions is needed to protect the patient and design nursing action and risk managing plans accordingly. ˚ Falls prevention ˚ To avoid overdose of drugs
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˚ The patient has a less risk of getting injuries like fractures.
˚ Patient has less risk of falls ˚ Patient feels safe in the ward ˚ Patients show no signs of side-effects after medications
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| Nursing problem: Fluid imbalances and nutrients deficiency | ||||
| Underlying cause or reason: Eating disorders, loss of bodily fluids through sweating or vomiting, decrease intake of fluid, medication that effects potassium balance
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| Goal of care | Nursing interventions/actions | Rationale | Indicators your plan is working | |
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To provide the patient proper nutrition i.e. to keeping well hydrated and timely fed.
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˚ Check fresh drinking water is at all times accessible
˚ Instruct the patient to drink water and increase fluid intake ˚ Supervise nutrition like vitamins or iron consumption and fluid intake ˚ Check patient served balanced meal on time. |
˚ Increased liquid intake would increase the blood flow and improve tissue perfusion (Engelheart and Akner, 2015)
˚ Improper nutritional level and less hydration lead to weakness in elders. ˚ To meet energy requirements
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˚ The patient show stable vital signs of pulse, heart rate, and normal breathing function.
˚ The patient is in a stable state of mind and skin is not pale, cold or sweating. ˚ Good dietary habits is observed ˚ No sudden fatigueless, dizziness or any respiratory infections is observed. |
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| Nursing problem: Risk for infection | ||||
| Underlying cause or reason: Compromised immune system and inadequate primary defences | ||||
| Goal of care | Nursing interventions/actions | Rationale | Indicators your plan is working | |
| To maintain patient personal hygiene and to keep comfortable
dressing
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˚ Arranges or provides bed bath
˚ Maintain the cleanliness of the patient ˚ Check equipment in shower and toilet is in working condition. ˚ Help and repeat the patient to develop practices of hand hygiene ˚ Check patient clothes and bedding are dry and changed every day. ˚ Check bed linen, sheets and patients clothes are washed on regular basis |
˚ Body cleanliness provide soothe the patient
˚ To make the patient comfortable ˚ To avoid contamination ˚ To lookout for any fluids exposure (Oliver, 2012) ˚ To prevent infection from clothing
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˚ The patient feels fresh.
˚ The patient shows a good mental stableness and calm behaviour. |
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| Nursing problem: Loss of control, lack of confidence and experience of discomfort | ||||
| Underlying cause or reason: Deteriorating health conditions, loss of memory, loss of social interactions, confusion, anxiety, attitude and behaviour of others people | ||||
| Goal of care | Nursing interventions/actions | Rationale | Indicators your plan is working | |
| To maintain the dignity and respect the privacy of the patient
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˚ Show care to the patient
˚ Treat and communicate patient with politeness ˚ Address the patient with its preferred name ˚ Actively listen to patients requirements , problems and feeling ˚ Maintain confidentiality of patient shared feelings and in discussing sensitive issues |
˚ Patient will feel respected and acknowledged
˚ Interactions with patient promote dignity and feeling of being valued (Tadd et al., 2011). ˚ Social needs of patient gets fulfilled to a certain extent by actively listening and communication ˚ Maintaining privacy increases the patient trust in receiving care plan. |
˚ Patient show less or no signs of depression.
˚ Patient feels relaxed and comfortable after interactions. |
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| Nursing problem: Impaired communication | ||||
| Underlying cause or reason:
Dyspnea, Loss of memory, respiratory problems, depression , prolonged illness, side effects of drugs, fatigue, sensory challenges in vision, breathing difficulties |
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| Goal of care | Nursing interventions/actions | Rationale | Indicators your plan is working | |
| To provide necessary information and education regarding the overall treatment and to patient and family and to communication with patient to develop relationship and rapport | ˚ Provide information about the current health status, precautions to be taken by the patient and future health risk and provide explanation for treatment procedure and complication
˚ Educate about medication and related side effects ˚ Communicate with patient both verbally and non-verbally (Burns and Grove, 2010)
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˚ To make the patient or family aware about risks involved in treatment
˚ To enhance participation of family in care plan (Hamric et al., 2013) ˚ This ensure that there is no confusion for the proposed treatments ˚ To ensure that health and individual needs are assessed ˚ To develop trust and rapport with patient |
˚ The patient and family ask questions and respond to treatment concerns.
˚ The patient or family make informed choice. ˚ Patient will feel less anxious. |
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Task 3: Medication Management
Rosie has been prescribed with the following medications for Acopia and falls:
Atorvastatin: This medication is useful in treating hypercholesteremia in patient as it lowers the cholesterol level (Egan et al., 2013). This mediation obstructs the bad cholesterol production. The specific nursing responsibilities in administering this medication include giving timely dosage of 20 mg daily to Rosie. It would also require monitoring lipid levels in patient for to confirm reduce level of low density lipid for remedial effectiveness. The responsibility of nurse is to for side effects in Rosie due to intake of this medication such as allergic reaction which can cause swelling of facial parts and throat, diarrhea, joint or muscle pain, problem with vision or sudden weakness (Drugs.com, 2017).
Ramipril: This medication is for treatment of hypertension condition in case of Rosie. This works to lower the high blood pressure, improve the function of cardiac and reduce the risk of heart failures. Apart for giving timely dosage of 10 mg daily to patient, the nursing responsibility also requires to perform regular check on blood pressure levels and monitor BP after four hours of dosage. It also requires examining for hypotension in salt. The nurse is required to note BP levels and observe for anti-hypertensive effects. The nurse needs to monitor Rosie for side-effects like difficulty in breathing and swallowing, no movement, facial swellings, swellings in ankle, dry mouth, severe stomach pain, no or excessive urination, unusual heart rate, sweating, nausea, and sudden weakness (Drugs.com, 2017).
Aspirin: This medication is high dosage of 100 mg daily is for cardio-protective effect. As Rosie is reported to have medical history of hypertension and hypercholesteremia make her vulnerable to chest pain, cardio related disorders and heart failures. The nursing responsibilities for administering aspirin to monitor daily dosage as directed, asses fever or pain in patient, observe any signs of overdose such as confusion, sweating, lethargy and diarrhea (Drugs.com, 2017). The nursing role also require to check for related side effects like stomach or intestinal bleeding, nausea or vomiting, fat breathing or heartburn, ulcers and signs of stomach pain for this drug.
Task 4: Patient Teaching
The nursing role plays a central role to make Rosie understand her risk factors for hypertension in current health status and required healthy lifestyle practices though patient teaching. The patient teaching stress on taking regular dosage of Ramipril medications but inform to stop the intake of drug in case of facial swellings, difficulty in swallowing salvia, food or water and breathing difficulties. It is essential to inform Rosie to maintain sufficient amount of liquid intake and a nutritious diet rich in iron till this medication continues for treatment. Rosie needs to be advised to avoid salt substitutes and any potassium supplements during this medication. This specific information is important to Rosie she is having medical history of hypertension and conditions of uncontrolled blood pressure can be one of the reason of falls. At old age, falls can lead to disability, serious injuries and fracture in Rosie. Rosie through patient teaching can be made aware that a little decrease in blood pressure level can help to reduce the morbidity of hypertension resulting from heart strokes, heart related diseases and reduce mortality causes. To make certain that Rosie has properly understood, the nurse can ask Rosie to keep a note of BP levels, makes a vitamins or nutrient rich diet plan and record instances of any falls in home and is required to communicate her heath status and BP level every week through phone or weekly mail.
Task 5: Clinical Judgment and Handover
According to the clinical judgment, Rosie is displaying symptoms related to side effects of Ramipril drug. Due to decrease in blood pressure Rosie feels gastrointestinal problems such as pain, sweating and nausea and reason for skin discoloration. The dysphonic condition in Rosie is related to problem of ineffective breathing which is due to fluid imbalances and nutrients deficiency in the patient. The immediate action to be taken is to elevate the position of bed to make sure Rosie is bended forward to reduce breathing difficulty and to reduce the problem of dyspnea. This is done to make sure that Rosie gets an easy position for better respiratory function. The nursing action requires taking a note of respiratory rate, pulsing rate and observe oxygen saturation level at room and the cardiac rhythm to identify the inhalation/expiration rate, to observe any irregularity in the heart rate and to monitor oxygen saturation level of the patient.
The handover of information from the ward to Coronary Care Unit for the patient is provided using the ISBAR format. The Rosie case requires information details to be given under the following sections:
Identify: This will include patient name (Rosie), date of birth and age (76 years), gender and location. It also includes patient MRN number and names and designation of the physician, physiotherapist, and the nursing staff managing patient case (Ratajczyk & Cushway, 2011). It will also display the names and designation of Coronary care unit doctors and nursing staff that will be handling the case.
Situation: It cover the reason for handling Rosie from ward to care unit which is for better management and closer monitoring of the patient.
Background: This will state the medical case history of Rosie being reported of conditions of hypertension, hypercholesteremia and left eye haematomas and bilaterally knees conditions. It also contains details about the dosage and prescribed medications. It will also state that the patient symptoms like loss of memory, tiredness and fatigue as well as post fall symptoms of anxiousness and breathlessness.
Assessment: It will provide details about the latest clinical observation of Rosie for its respiration rates, oxygen saturation level, blood pressure levels, pulse, and its recent condition such as ineffective breathing, dyspnoeic, rapid respiration, anxiety, skin discoloration due to nutrients deficiency and dehydration symptoms along with side effects of Ramipril medication.
Recommendation: It is suggested the care unit carry a risk assessment of environmental hazards and health related examination to check for falls, maintains a high liquid intake and a diet with nutrients (vitamins such as iron) with ongoing medication.
References
Burns, N., & Grove, S. K. (2010). Understanding nursing research: Building an evidence-based practice. United States: Elsevier Health Sciences.
Drugs.com (2017). Drug Side Effects. Retrieved from: https://www.drugs.com/sfx/
Egan, B. M., Li, J., Qanungo, S., & Wolfman, T. E. (2013). Blood pressure and cholesterol control in hypertensive hypercholesterolemic patients. Circulation, 128(1), 29-41.
Engelheart, S., & Akner, G. (2015). Dietary intake of energy, nutrients and water in elderly people living at home or in nursing home. The journal of nutrition, health & aging, 19(3), 265.
Hamric, A. B., Hanson, C. M., Tracy, M. F., & O’Grady, E. T. (2013). Advanced practice nursing: An integrative approach. United States: Elsevier Health Sciences.
Kalisch, B. J., Tschannen, D., & Lee, K. H. (2012). Missed nursing care, staffing, and patient falls. Journal of nursing care quality, 27(1), 6-12.
Oliver, D. (2012). Transforming care for older people in hospital: physicians must embrace the challenge. Clinical Medicine, 12(3), 230-234.
Ratajczyk, E., & Cushway, S. (2011). ISBAR for Intensive Care Nurses. HNE Handover: For Nurses and Midwives, 4(1).
Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., & Read, S. (2011). Right place-wrong person: dignity in the acute care of older people. Quality in Ageing and Older Adults, 12(1), 33-43.
