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Nursing Care Of A Person In A Medical Surgical Setting
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Nursing Care Of A Person In A Medical Surgical Setting
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Question:
Jim is a 58 year old homeless Indigenous male of no fixed address. He presented to the Emergency Department with dyspnea, myalgia, fatigue, malaise, rhinorrhea and headache. His symptoms began approximately 1 day ago and are continuous and steadily getting worse. On examination he was found to be febrile with a clear nasal discharge, shortness of breath and muscle soreness. He has a previous medical history of asymptomatic hypertension but is not currently prescribed antihypertensive medication as he did not take this medication when previously prescribed. He is allergic to chickens but has no known drug allergies. He states he used to smoke but not so much anymore as he cannot afford them however he does smoke up to 5 – 10 per day if he can get them. Discuss about the Case Study.
Answer:
Blood pressure, breathing and infection are the three areas in which assessment for Jim need to be carried out. Assessment for blood pressure in Jim need to be carried because his blood pressure reading indicates he is having hypertension. His blood pressure is 158/86 mmHg and normal blood pressure should be 120/80 mmHg. It indicates his blood pressure raised above normal level. Blood pressure assessment can be carried out using sphygmomanometer. Blood pressure is sensitive parameter. It can change based on the activity and sitting position. Hence, blood pressure assessment need to be carried out in varied conditions of patient to get robust assessment of hypertension in Jim. White blood cells (WBC) can increase above normal level in patients with infection. Hence, along with culturing of sputum and nasal secretion samples for influenza A virus, WBC analysis need to be carried out in Jim. Breathing pattern and breathing rate need to be assessed in Jim to assess functioning of respiratory tract. Jim is exhibiting insufficient breathing due to abnormal functioning of respiratory system. It is evident that influenza infection can affect respiratory tract (White et al., 2012).
It would be helpful to plan effective nursing intervention for Jim through assessment of blood pressure, infection and breathing. Specific antibiotic can be administered by identifying specific organism like influenza A virus because other antibiotics might not work in the infection caused by influenza A virus. Influenza A virus has potential to affect respiratory system. Hence, there might be dysfunction of the respiratory system. It produces insufficient breathing in Jim. As a result, there can be less oxygen supply to other organs. Hence, heart starts pumping at faster rate. It can produce hypertension in Jim. It indicates influenza A virus infection can lead to multiple organ dysfunction. Due to this multiple organ dysfunction, there can be deterioration of Jim. Hence, to assess deterioration of Jim, assessment of blood pressure, infection and breathing need to carried out in Jim (Shannon et al., 2013).
Nursing problem: Risk of spread of infection
Underlying cause or reason: Influenza virus can be easily transmitted to the immunosuppressed patients in the hospital.
Goal of care
Nursing interventions/actions
Rationale
Indicators your plan is working
To prevent and control spread of infection in the clinical setting.
Assessment of influenza A virus infection by culturing sample of sputum and nasal secretions.
Analyse WBC.
Inspire patient to use face mask at the time of speaking, coughing and sneezing.
Educate Jim about importance of cleaning hands and articles used by him with antiseptic and demonstrate him the procedure for the same.
Encourage patient to follow hand cleaning and article disinfection procedure.
Encourage patient to wear PPEs like glove and gown.
Arrange separate accommodation for patient and warn patient to keep away from the crowded places during the period of infection.
Consult physician and administer patient with suitable antibiotic.
Encourage patient to adhere to the antibiotic consumption and ask patient to complete the course of antibiotic.
Intervention can be planned in advance based on the assessment (White et al., 2012; Carpenito, 2013).
There can be increase in the WBC count in infection (Lemone et al., 2017)
Infection can be prevented during speaking, coughing and sneezing by using mask (White et al., 2012; Li et al., 2014)
Hand washing with antiseptic and decontaminating articles can be used to prevent indirect spread of infection (Patel et al., 2014; Manfredi and D’Onofrio, 2013).
Isolated environment for patients can be helpful in preventing spread of infection (Patel et al., 2014).
Prevention and control of infection can be effectively achieved by using suitable antibiotic (Patel et al., 2014; Manfredi and D’Onofrio, 2013).
Jim is free of all the symptoms associated with influenza infection.
There are no cultures of influenza virus in the sputum and nasal secretion samples of Jim.
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 patient to complete daily activities with ease.
To reduce risk of respiratory insufficiency, to reduce fatigue and to improve capability to complete the task.
Assess patient’s capacity to complete daily activities.
Arrange walker for patient to walk without fear of fall.
Provide assistance in completing daily activities. Allow patient to be in the isolated place so that patient would not feel embraced while performing his activities.
Encourage him to perform all his activities at his wish and do not enforce him to these activities.
Encourage family members to help in his daily activities.
Assess vital signs of patient before and after completion of activities. These vital signs should include blood pressure, respiratory rate and heart rate.
Encourage patient to take frequent rest periods in between the activities.
Discuss with doctor and provide him with artificial oxygen.
Encourage patient so that there can be improvement in the self-confidence of the patient.
Intervention to augment activity level can be planned after early assessment of the patient (Gulanick and Myers, 2016).
Self-sufficiency can be improved by providing limited assistance
(Seed and Torkelson, 2012).
Deterioration of the patient can be assessed effectively by evaluating vital signs in the patient (Doenges et al., 2016; Yates et al., 2014)
Burden for the completion of activities can be reduced (Doenges et al., 2016; Yates et al., 2014). Fatigue level can be reduced by storing energy reserve through rest periods (Doenges et al., 2016)
Normal functioning of the respiratory system can have restored which can reduce fatigue level. Improvement in the self-confidence can improve morale to perform after completion of the treatment (Potter et al., 2013
Functioning of the respiratory system improved in the Jim.
Jim is being performing activities with ease.
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: Inadequate fluid intake and loss of fluid due to vomiting.
Goal of care
Nursing interventions/actions
Rationale
Indicators your plan is working
To maintain optimum fluid balance and preserve hydrating condition in Jim
Record fluid intake and output and maintain it in the form of chart.
Measure body weight on regular basis and record it in the patient file.
Measure vital signs like blood pressure, respiratory rate and temperature in frequent intervals.
Asses dryness by monitoring oral mucosa and skin turgor.
Assess orientation using Glasgow coma scale.
Accurate requirement of the fluid for the patient can be assessed by using these charts (McGloin, 2015).
Insufficient intake of fluid can reduce body weight and exhibit symptoms like tachypnoea, hypotension and tachycardia (McGloin, 2015).
Dehydration in the patient can assessed through dryness of oral mucosa and skin turgor (McGloin, 2015).
Reduced fluid intake can lead to altered fluid balance in the patient which can lead to altered orientation in the patient (McGloin, 2015).
Jim is consuming optimum amount of fluid with respect to his needs.
Oral mucosa and skin turgor are normal.
Nursing problem: Risk of constipation
Underlying cause or reason: Insufficient intake of diet.
Goal of care
Nursing interventions/actions
Rationale
Indicators your plan is working
Jim need to defecate with ease.
Evaluate stool consistency and stool frequency.
Encourage patient to consume warm water on regular basis.
Jim need to consume nutritious food in optimum quantity and on regular basis.
Discuss with physician and prescribe patient with bulk laxatives.
Abnormality in frequency and consistency of defecation can be evaluated (Costilla and Foxx-Orenstein, 2014).
Stool become softened and easy to defecate (Costilla and Foxx-Orenstein, 2014).
Liquid diet can soften the stools and solid diet can improve consistency of stool (Costilla and Foxx-Orenstein, 2014).
Constipation can be eliminated in the patient (Costilla and Foxx-Orenstein, 2014).
Jim is having normal defection on regular basis.
Normal and well-formed stools.
There is no stress on Jim during defecation.
Nursing problem: Risk of depression and anxiety.
Underlying cause or reason: Depression and anxiety due to hypertension and increased respiratory rate.
Goal of care
Nursing interventions/actions
Rationale
Indicators your plan is working
To encourage Jim to express his depression and anxiety.
Assessment of extent of depression and anxiety.
Recognise physical response to depression and anxiety.
Provide education and counselling to Jim related to depression and anxiety.
Appropriate intervention can be planned for Jim (Gulanick and Myers, 2016)
Anxiety and depression can lead to weakness and inactivity (Gulanick and Myers, 2016).
It can be helpful in reducing stress related to depression and anxiety (Gulanick and Myers, 2016).
Jim expressed about his depression and anxiety.
Jim is not exhibiting signs and symptoms of depression and anxiety.
Oseltamivir is an antiviral agent. Both influenza A and influenza B infections can be effectively treated with oseltamivir. It can be more effective, if it administered within 48 hours of infection. To assess effectiveness of oseltamivir, nurse should assess fever, cough, headache, fatigue, muscular weakness and sore throat. These are the symptoms of infection and these symptoms can be improved after administration of oseltamivir. After assessment, if nurse couldn’t find improvement in his condition, nurse need to consult to physician to shift to another medication. It is evident that oseltamivir can produce psychological effects. Hence, nurse need to assess psychological abnormalities by providing questionary and seeking response to the same (Skidmore-Roth, 2015).
Paracetamol can be administered in the patients with pain and fever. Handover data specify that Jim is having fever. To bring his body temperature to the normal level, Jim need be administered with paracetamol. Nurse should check his body temperature after administration of paracetamol with short intervals and assess improvements in Jim. If nurse couldn’t find any improvement Jim, nurse should consult with physician for change in the dose of paracetamol. It is evident that paracetamol should not be taken on the empty stomach, hence nurse should make sure that Jim is consuming enough diet prior to paracetamol consumption. In clinical settings, it is evident that paracetamol can produce liver toxicity, hence nurse should perform liver function test to assess liver toxicity of paracetamol (Skidmore-Roth, 2015).
Fluvax is a vaccine which has effect of influenza infection prevention. To aid improved efficacy of Fluvax, it need to be administered every year. Antibodies present in the Fluvax can exhibit its efficacy upto 6 months. Hence, nurse need to be administer it once a year. Fluvax can produce hypersensitivity to eggs and other constituents of Fluvax, hence nurse need to assess patient’s allergic reactions to these constitutes (Skidmore-Roth, 2015).
Jim need to be educated for every aspect of influenza infection. It includes types of influenza infections, types of transmissions and methods of their prevention. Influenza virus can be transmitted either through direct or indirect mode. Direct transmission can occur through coughing and sneezing without any protection. Indirect transmission can occur through hand contacts of infected patient and by utilizing article used by the infected patient. Nurse should educate Jim about importance of cleaning hands and explain him about procedures to be followed for cleaning hands with antiseptic. Nurse need to educate him to decontaminate articles used by him. Jim should be educated about the use of PPEs like mask, gloves and gown. Nurse need to explain Jim that use of these PPEs can be helpful in reducing chances of influenza A virus transmission. Jim should be educated about signs and symptoms of influenza A infection. Hence, Jim can recognize it and can inform nurse about the same. Early reporting of the infection can be helpful to plan effective intervention for Jim. Prevention of influenza virus infection not only useful for Jim but also can be useful for other also. Its prevention can be helpful in reducing risk of re-infection in Jim. In case, there is increase in the number of patients for influenza infection, it can lead to overburden for hospital and it would be difficult to provide proper care to the influenza patients including Jim. Prevention and control of influenza infection is very important in Jim because it can adversely affect multiple organs. Due to this multiple organ damage, there can be deterioration of Jim. Jim need to be kept in the isolated environment for the prevention of spread on infection (Jardins and Burton, 2015; Beachey, 2018). :
It is evident that influenza infection can affect respiratory system functioning which can result in altered breathing pattern. Jim is infected with influenza virus, hence there is dysfunction of respiratory system in him. As a result, his lungs are unable to perform normally. It adversely impacts gaseous exchange at alveoli wall and capillary wall interface. It resulted in reduced oxygen saturation level in the blood. As a result, different organs of Jim can’t receive optimum amount oxygen for their normal functioning. Heart recognise this deficiency in oxygen and initiate speedy heart pumping. It results in the augmented heart rate and blood pressure in Jim. To compensate, deficiency of oxygen lungs need to breath at faster rate. Hence, there is increased respiratory rate in Jim. Due to increased heart rate, blood pressure and respiratory rate, there is increase in the body temperature of Jim. He is also experiencing shivering (Morton and Fontaine, 2017).
To improve this condition Jim need to improve his breathing pattern. Breathing pattern an be achieved by suppling artificial oxygen to Jim. In addition to this, Jim need to be administered with medications like antihypertensive, bronchodilator and antipyretic medicines. Administration of these medicines can be helpful in improving vital signs like heart rate, blood pressure, respiratory rate and body temperature. Deviation from the normal values for these vital signs indicate dysfunction and deterioration of organs like heart and lung. Immediate intervention can be helpful in preventing deterioration of these organs in Jim.
I am a nursing student in the medical-surgical ward. I am taking care of patient Jim. He was suffering through influenza A infection, however after administration of medicines, there is improvement in his condition. However, today morning he was exhibiting symptoms like fever and shivering. His breathing pattern and speech was not normal. Recorded vital signs for Jim are body temperature 39.6?C, heart rate 125 bpm, respiratory rate 24 bpm, blood pressure 124/79 mm/Hg and oxygen saturation 86 %. Careful observation of Jim is required. After assessment of Jim, doctor decided to shift Jim to the High Dependency Unit to provide BIPAP.
References:
Beachey, W. (2018). Respiratory Care Anatomy and Physiology: Foundations for Clinical Practice. Elsevier Health Sciences.
Berman, A., Shirlee, J. S., Barbara, K., ….. Stanley, D. (2014). Kozier & Erb’s Fundamentals of Nursing Australian Edition. Pearson Higher Education AU.
Carpenito, L. J. (2013). Nursing Care Plans: Transitional Patient & Family Centered Care. Lippincott Williams & Wilkins.
Costilla, V.C., and Foxx-Orenstein, A.E. (2014). Constipation: understanding mechanisms and management. Clinics in Geriatric Medicine, 30(1), 107-15.
Doenges, M. E., Moorhouse, M. F., and Murr, A. C. (2016). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales. F.A. Davis.
Gulanick, M., and Myers, J.L. (2016). Nursing Care Plans – E-Book: Nursing Diagnosis and Intervention. Elsevier Health Sciences.
Jardins, D., and Burton, G. G. (2015). Clinical Manifestations & Assessment of Respiratory Disease – E-Book. Elsevier Health Sciences.
Manfredi, P., and D’Onofrio, A. (2013). Modeling the Interplay Between Human Behavior and the Spread of Infectious Disease. Springer Science & Business Media
McGloin, S. (2015). The ins and outs of fluid balance in the acutely ill patient. British Journal of Nursing, 24(1). doi: 10.12968/bjon.2015.24.1.14
Morton, P. G. and Fontaine, D. K. (2017). Critical Care Nursing: A Holistic Approach. Lippincott Williams & Wilkins.
Lemone, P., Burke, K., Bauldoff, G., Gubrud, P., Levett-Jones, T., Hales, M., … Reid-Searl, K. (2017). Medical-surgical nursing, critical thinking for person-centred care. (3rd Australian ed.). Melbourne, Victoria: Pearson Australia.
Patel, D.B., Emmanuel, N.B., Stevanovic, M.V., Matcuk, G.R.. Jr, Gottsegen, C.J., Forrester, D.M., and White, E.A. (2014). Hand infections: anatomy, types and spread of infection, imaging findings, and treatment options. Radiographics, 34(7), 1968-86.
Potter, P.A., Perry, A. G., Stockert, P., and Hall, A. (2013). Fundamentals of Nursing – E-Book. Elsevier Health Sciences.
Seed, M.S., and Torkelson, D.J. (2012). Beginning the recovery journey in acute psychiatric care: using concepts from Orem’s Self-Care Deficit Nursing Theory. Issues in Mental Health Nursing, 33(6), 394-8.
Shannon, S. L., Dirksen, R., and Heitkemper, M. M. (2013). Linda Bucher Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Health Sciences.
Skidmore-Roth, L. (2015). Mosby’s Drug Guide for Nursing Students. Elsevier Health Sciences.
Tiziani, A. P. (2013). Havard’s nursing guide to drugs (9th ed.). Elsevier Health Sciences.
Ward, J. P. T., Ward, J., and John, R. (2015). The Respiratory System at a Glance. Wiley & Sons.
White, L., Duncan, G., and Baumle, W. (2012). Medical Surgical Nursing: An Integrated Approach. Cengage Learning.
Yates, T., Davies, M.J., Edwardson, C., Bodicoat, D.H., Biddle, S.J., and Khunti, K. (2014). Adverse responses and physical activity: secondary analysis of the PREPARE trial. Medicine & Science in Sports & Exercise, 46(8), 1617-23.
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