In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice
? Identify 3 specific nursing assessments that you would conduct as a priority for Jim’s nursing care that you will undertake on Jim’s admission to your ward.
For each assessment you have identified explain:
? Why the assessment is relevant to Jim’s care.
? What consequences may occur if this assessment is not completed accurately?
(300 words, 10 marks)
Based solely on the handover you have received and using the template provided, develop a care plan for five (5) nursing problems related to fundamentals of care from Week 1 learning materials.The first 3 nursing problems have been identified and are included in the template. These nursing problems cannot be changed and a care plan needs to be developed for each. Your task is to identify another 2 priority nursing problems related to fundamental care needs and for each of the 5 nursing problems identify:
? Goal of care
? Specific bedside nursing interventions you will do
? The rationales for your nursing interventions and actions
? Indicators that your plan is working
Task 3: Medication management
Three important aspects of medication management by registered nurses is for the nurse to understand why a patient has been prescribed specific medications, understanding the nursing responsibilities and how to monitor the patient to ensure they are responding to prescribed medications as they should.
In grammatically correct sentences and topic paragraphs and using current, reliable evidence for practice,
o Oseltamivir 75mg orally bd
o Paracetamol 4/24 orally prn
o Fluvax IM stat dose
? Identify and explain
o The specific nursing responsibilities associated with administering each medication
o How you will monitor Jim for expected, side and adverse effects of each medication.
Task 4: Patient teaching
You recognise part of your nursing role is to provide Jim with education on:
o Preventing and controlling the incidence and spread of influenza
o Reducing the modifiable risk factors for hypertension
o Health promotion and minimising risk of hospitalisation
Select one (1) of the topics above and, in grammatically correct sentences and topic paragraphs,
? Identify the specific information you will need to explain to Jim about the topic
o Why the topic is an important aspect of Jim’s care
o How you will ensure that Jim knows and understands why it is important and, if appropriate to the topic, what he needs to do
MEDICAL/ SURGICAL NURSING
• Self care deficit
• Influenza A
When Jim is admitted to the ward, he has shown symptoms of preliminary Influenza and has also commenced an oseltamivir which is the results of his flu swab. His symptoms occurred 1 day ago and he continuously getting worse. While examining the patient problem, it is being ascertained that Jim was found to be febrile with a clear and nasal discharge, shortness of breath and muscle soreness (Alligood, 2017). Considering, his previous medical condition, it is analyzed that Jim had asymptomatic hypertension; however currently he is not prescribed antihypertensive medication. Nurses has also diagnosed that Jim does not consume any such prescribed medication; thus no medicine is yet given to him. At the same time, he is also allergic to chickens; but has not shown any sort of drug allergies. Jim has also stated that he used to smoke but currently is not smoking as he cannot afford it.
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Nursing problem: Risk of spread of infection
Nursing problem: Self care deficit
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: This is the state of decreased intravascular, interstitial and intracellular fluid. This is also known as the situation of dehydration and water loss without having any change in the sodium (Johny et al. 2017). In this context, the intake of fluid is less in Jim as compared to the fluid output. It happens in Jim because water and electrolytes are lost as they exist in normal body fluids. There should be appropriate management for fluid intake as long term imbalance may cause vascular, cellular or intracellular dehydration.
Nursing problem: Asymptomatic hypertension
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To reduce the risk of cardiovascular disease, stroke, renal disease and death. Immediate diagnostic testing is essential in terms of short-term management and this is also useful in controlling blood pressure level. This can be best achieved through adjusting with antihypertensive therapy. However, in this case, aggressive lowering of blood pressure should be avoided by giving parenteral medications This sort of treatment is essential so that chances of occurring other risks can be reduced. There will be proper checking of blood pressure level on continuous basis. This is essential for suitable treatment.
Underlying cause or reason: This sort of problem is most often caused by any type of injury to the bones, joints, muscles, tendons ligaments or nerves. Typically, it is caused by jerking movements, fractures and sprains. Since, Jim has no specific place to reside; therefore he does not have any sort of rest for his body (Melin?Johansson, Palmqvist & Rönnberg, 2017). Hence, it can be said that due to prolonged immobilisation, the chances of risk can increase more.
Goal of care Nursing interventions/actions Rationale Indicators your plan is working
To ensure that Jim is having joint movements by focusing on different therapeutical aspects. It can be treated with specific therapies and also through facilitating direct movement of joints. Along with this, medications can also be provided to enhance body’s level of serotonin and norepinephrine. The provided medication will also assist Jim, to sleep properly and it can also result in speedy recovery. Nurses will ensure if Jim is continuously having movements of joints.
• Oseltamivir 75mg orally bd has been provided to Jim during Influenza epidemic. It is also called as influenza neuraminidase inhibitor which will prevent the flu. During bedside, the medicine will be provided directly by the nurses because Jim is careless is taking medicines.
• Paracetamol 4/24 has also been provided to Jim so as to reduce the problem of headache and other analgesic effects. The medicine will also help Jim to control the nasal cavity by regular consumption of the medication. Here, nurses need to check if proper dosage is being given to Jim as per the prescription. This way, there will be proper medication administration for Jim’s case (Rahmani et al. 2017).
• Fluvax IM stat dose is also given to Jim for the purpose of mitigating the impact of virus on other body parts. The virus may impact other body parts and organs; therefore proper medication is essential in this respect. This is also crucial for the purpose of protecting Jim from all sorts of co-morbid harms and injuries.
However, the selected topic of reducing risk factors for hypertension is an important aspect of Jim’s care as increasing and uncontrollable hypertension results in ischemic heart disease that lead to patient die with the stroke. Along with this, educating on the topic also results in changing their lifestyle that can aid Jim in controlling their high blood pressure that further diminish the danger of life-threatening difficulties (Santos, Ramos & Fonseca, 2017). After imparting the education or knowledge on the important topic nurse will engage in diagnose the level of blood pressure in Jim’s body. In the situation if there is increase in the blood pressure rate then in such case it will be identified that Jim has not followed accordant with the prescribed medication and treatment.
Temperature 39.6 C
Heart rate 125 beats per min
Respiratory rate 24 resps per min
Blood pressure 124/79 mmHg
O2 saturations 86% on room air
With the help of reviewing vital sign it was identified that Jim temperature was above the normal temperature that results in feeling cold to Jim (Ueda, Mizuguchi, Sasaki & Yokoyama, 2017). On the other hand, Respiratory rate of Jim was also high that is 24 resps per min that lead to intake more air. In this situation nurse actions and intervention must focuses on allowing oxygen mask to Jim so that it normal the respiratory rate.
To impart effective services and nursing care to Jim, nurses are required to implement the legal requirement that engages in imparting effectively and concisely transferring of the relevant information, actions and outcomes of patient care through reviewing the health of the patient. With the help of communicating relevant information, it results in-
• Identifying the health and nursing care plan of Jim
• After that, it focuses on analysing the situation of Jim that is he has improved his health or not (Urden, Stacy & Lough, 2017)
• It also engages in assessing the background of the patient to impart proper care and treatment
For the continuation of nursing care of Jim it has been stated the nurse should also engage in imparting person centered care. With the help of this they empower patient to take health services and treatment accordant with their requirement.
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