NUR250 Medical Surgical Nursing Plan Assessment 1 Answer

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Question :

NUR250 Medical Surgical Nursing 1 S1 2020

NUR250 Assessment 1

Topic: Nursing care of a patient with a medical condition

Assessment purpose
Learning objectives
Assessment 1 is the only written academic assignment in NUR250 for students to demonstrate they:
  • Are developing the ability to locate, interpret, integrate, synthesize and apply nursing knowledge from NUR250 to a relevant nursing practice scenario in medical surgical settings
  • Are developing appropriate critical thinking, clinical reasoning and sound clinical decision making processes and strategies essential for safe, evidence-based and competent nursing practice in medical surgical settings
  • Are able to focus their attention to the needs of the individual patient as the key concern of nursing practice in medical surgical settings
  • Are able to explain and justify or defend their nursing care decisions
  • Have a developing understanding of the role and scope of practice of the registered nurse in the Australian health care context
  • Are progressing towards the level of professional written communication required for nursing practice in Australia
  • Are demonstrating ethical and professional practice by adhering
to the University’s academic integrity standards and plagiarism
This assessment addresses the unit learning outcomes; 1, 2, 3, 4 and 5

Preparation

  • Timely completion of study materials including weeks 1-6 with participation or review of online collaborate sessions, pre-recorded lectures or internal classes.

Presentation Guidelines

  • On the Assessment 1 template located in the Assessment 1 folder on NUR250 Learnline
  • As a computer generated document in Word format.
  • 1.5 spaced using Arial or Calibri font in size 11 or 12
  • In clear, coherent Australian English that demonstrates progression towards the standard for written communication for professional nursing practice in Australia.
  • Written in third person narrative.
  • Using appropriate professional terminology

Contents page, title page, introduction and conclusion are NOT required

  • Unless otherwise indicated, no acronyms, abbreviations and/or nursing jargon
  • Unless otherwise indicated, grammatically correct sentences and topic paragraphs are required. Dot points only accepted in the nursing care plan.
  • No more than 10% over or under the stated word count. Marking will cease at the 10% over mark.

o Note: Headings, any task information copied in and in-text citations are included in the word count. 100 words have been included in the word count to account for the headings within the nursing care plan template.

  • Use of trade names is not acceptable. Only generic terms or names are to be used when referring to specific medications or other prescribed treatments or resources that may be used in nursing practice.

Referencing

Students are reminded of their academic responsibilities and professional nursing practice requirements when using the work of others in assignments.

Reminder marks are allocated for academic integrity. See the marking criteria for Assessment 1 for full details. Breaches of academic integrity will be lodged on the University system and may have serious consequences for students.

  • All information is to be interpreted and restated in your own original words demonstrating your ability to interpret, understand and paraphrase material from your sources
  • CDU APA 7th referencing style is to be used for both in-text citations and end of assessment reference list.
  • All resources for NUR250 assignments should be from quality, reliable and reputable journals relevant to nursing practice and the Australian healthcare industry. Please DO NOT use patient information leaflets.
  • All resources must be dated between 2010 and 2020

There must be at least 10 peer-reviewed journal articles and/or evidence-based practice guidelines cited in your assignment.

  • Do not use any health facility or local health service policies or procedures
  • Only 1 current Australian medication textbook and 2 current Australian medical surgical nursing textbooks to be referenced.

Please complete the assessment task on the next page.

Assessment 1: Case scenario one

Shift handover:

Identify:
Mr Robert Lalara, HRN: 123456, DOB: 20/01/1978
Situation:
Robert is a 42 year old Indigenous man from a remote community. He has been admitted to the CDU medical ward with chest pain and a ‘racing heart’. His ECG shows Atrial Fibrillation (AF).
Background:
Robert lives in a single-story home with his wife, 4 children and 2 grandchildren. He is independent with his cares.
He has an extensive past medical history including:
T2DM, smoker (10 per day), HTN, hyperlipidaemia, rheumatic heart disease and mitral valve regurgitation.
No known drug allergies (NKDA).
Assessment:
Airway: Own, patent
Breathing: RR 18, oxygen saturations 96% on room air. Circulation: HR 115 bpm (irregular), BP 120/80 mmHg. His ECG shows Atrial Fibrillation (AF)
Disability: GCS 15/15, 2/10 central chest pain, feels tired and a ‘bit worried’.
Exposure: Temp 37.0 oC
Recommendations/Read back:
Medical orders
  • Repeat ECG
  • Pain management
  • TED stockings and DVT prophylaxis
Medication orders
New medications:
  • Digoxin 125mcg PO STAT
  • Rivaroxaban 20mg OD PO Usual medications:
  • Ramipril 10mg OD PO
  • Simvastatin 20mg OD PO

Assessment 1: Case scenario two

Shift handover:

Identify:
Ms Laura Purple, HRN: 123678, DOB: 16/09/1960
Situation:
Laura is a 59 year old Caucasian lady from Darwin. She has been admitted to the CDU medical ward with Bronchitis. She has a 1/7 history of dyspnoea.
Background:
Laura lives in a two-story home with her husband. She is independent with her cares.
She has a past medical history of:
Asthma, T2DM, smoker (20 per day), hyperlipidaemia and obesity. No knowndrug allergies (NKDA).
She is obese (BMI 30) and drinks 1 bottle of wine every night.
Assessment:
Airway: Own, patent
Breathing: RR 28, Sats 93% on room air. Expiratory wheeze noted. Circulation: HR 115 bpm, BP 130/90 mmHg.
Disability: GCS 15/15, 2/10 sharp chest pain on inspiration Exposure: Te Show More

Answer :

NUR250 Assessment 1 S1 2020 Assessment One Template

Task 1 

Acute bronchitis is a serious condition that can results in reversible bronchial inflammation. The major cause of the infection is viral, and it is one of the most common diagnoses made by primary care physicians (Wark, 2015). The reason of such a common diagnosis is that physicians often lump various conditions together while making a diagnosis. There are several symptoms and vital signs reported by Ms Laura Purple indicating that it is a case of acute bronchitis.

Considering the pathophysiology of acute bronchitis there is an irritation of the cells of the bronchial-lining tissues resulting in hyperemic and edematous of the mucous membrane leading to a diminishing bronchial mucociliary function (Chang et al., 2019). This makes air passages blocked by debris thereby developing copious secretion of mucus becoming a major cause of cough of acute bronchitis (Ehrlich et al., 2010)

Laura’s history of dyspnea and asthma shows signs of expiratory wheezing while having a patent airway. Dyspnea has the most common pulmonary cause in the form of obstructive and restrictive processes where the obstructive causes includes asthma (Anzueto and Miravitlles, 2017). Both causes are present in medical history of Laura. Moreover, her lifestyle and medical history of asthma, T2DM, smoking, hyperlipidemia and obesity further complicate her condition while exposing her to serious condition of chronic toxic exposure (Santi et al., 2017 and Aanerud et al., 2015). Here, it is important to understand that with the underlying presence of inflammation, like in case of asthmatics and smokers, there are high chances of infective agents causing more severe cough and wheezing (Aanerud et al., 2015). Also, people with diabetes have higher rates of asthma and several pulmonary conditions like pneumonia (Enrlich et al., 2010). It is to be noted that diabetes complications result in several pathological changes including the blood vessels, cranial and peripheral nerves along with the lungs as a major target organ for diabetic microangiopathy (Ehrlich et al., 2010). 

This is evident in case of Ms Laura as she is being admitted with a sharp chest pain on inspiration along with a temperature of 38.6 oC clarifying the increased inflammation of lungs that could result in acute bronchitis or viral pneumonia.

This makes it important to provide medical orders based on safety of overall well-being of the patient. Steps are taken to avoid a case of pulmonary embolism where a blood clot may be formed elsewhere in the body and travels to the lung (Bertoletti, 2017). Generally, such a blood clot is formed in a vein deep in an arm or leg (DVT) and breaks off, travelling to the lung through the heart thereby blocking the supply of blood to certain portions of the lung (Bertoletti, 2017). A sharp chest pain with shortness of breath and rapid heart/circulation rate (100bpm) increases the risk of pulmonary embolism for Laura making it necessary to prescribe TED stocking and DVT prophylaxis as such a condition may cause sudden death (Konstantinides et al., 2014). 

Considering the degree of inflammation, the administration of Prednisolone is suggested to enhance the anti-inflammatory effects of the steroids produced with the patient’s body by the adrenal glands. There is a need of extra precautions and medications along with the regular prescription of Ipratropium bromide MDI and Salbutamol MDI making Azithromycin and Prednisolone important in controlling the inflammation. 

Task 2 

Nursing Care Plan: (Ms. Laura Purple)

Nursing problem: Risk of infection
Related to:  Risk of bacterial infection in the form of Pneumonia with fever as evidenced by Laura’s report of sharp chest pain, wheeze and high HR of 115 bpm
Goal of care
Nursing interventions
Rationale
Evaluation
Laura’s HR is below 10 bpm and easy breathing with no signs of wheeze and chest pain on inspiration







  • Immediately reporting in case of an increase or change in respiratory pattern and cough
  • Administer supplemental oxygen as prescribed
  • Administer prescribed medications in a proper and timely manner
  • Encouraging adequate rest and avoiding bronchial irritants
  • Boosting secretion via ambulation, coughing and deep breathing


  • Reducing any chances of airway collapse, dyspnea and making breath work through improving oxygen delivery (Altiner et al., 2010)
  • Deep suctioning many be required with ineffective cough for expectoration of secretions (Saust et al., 2018)
  • New medicines will help in controlling the condition as Prednisolone helps in reducing inflammation (Fayyaz and Mosenifar, 2019).
  • DVT prophylaxis will ensure non-formation of blood clots that can travel to lungs (Bertoletti, 2017)



  • Laura appears comfortable with easy breathing and no secretion and no chest pain
  • Laura’s vital signs are WNL



Nursing problem: Impaired tissue perfusion
Related to:  Oxygen therapy and TED stocking and DVT prophylaxis as ordered for the patient
Goal of care
Nursing interventions
Rationale
Evaluation

Laura reports adequate perfusion throughout the care 








  • Assessment and documentation of vital signs and reporting of any escalating changes.
  • Administration of prescribed medication and supplemental oxygen
  • Providing tracheostomy care and chest physical therapy along with deep breathing exercises every 4 hours. 
  • Observation for signs of thrombophlebitis and DVT.
  • Administering use of TED stockings as per prescribed duration


  • Increased risk of thrombophlebitis and deep venous thrombosis (Ehrlich et al., 2010)

  • Increased risk of tissue perfusion due to blood clots (Bernard et al., 2010)

  • Increased risk of bronchial obstruction and pneumonia (Bernard et al., 2010)

  • Issues of respiratory arrest and insufficiency (Saust et al., 2018)
  • Diabetes can induce microvascular abnormality through oxidative stress and inflammation (bernard et al., 2010)

  • Laura’s vital signs WNL
  • Laura reports absence of chest pain while inhaling
  • Ability to sustain spontaneous ventilation


Nursing problem: Knowledge deficit
Related to:  Habit of excessive smoking, alcohol intake and obesity along with history of T2DM and asthma and hyperlipidaemia 
Goal of care
Nursing interventions
Rationale
Evaluation

Change in lifestyle and proper understanding of symptoms and risk factors associated with asthma and acute bronchitis















  • Describe the process of disease, cause and factors contributing to acute state of bronchitis and risk of pneumonia.
  • Describe the procedures and symptom control methods to bringing lifestyle change for quitting smoking and alcohol intake.
  • Assess readiness of Laura to learn by assessing emotional response to illness in the form of anger, anxiety, acceptance or denial.
  • Allowing Laura to work through and express her emotions along with developing a desire to learn through a preferred mode like group work, one to one session, visual or auditory method.
  • Educate the individual for recognizing and reporting any symptoms of asthma and acute bronchitis

  • Identifying the triggers will help Laura to control the episodes of chronic asthma attack (Pellico et al., 2012). 
  • Correct breathing exercise and lifestyle changes will reduce the changes of further infection (Pellico et al., 2012).
  • Knowledge of readiness of the patient proves to be effective in identifying the correct time and appropriate intervention needed (Ackley et al., 2019).

  • Acute bronchitis and asthma being a chronic disease, there is a need for patient to able self-manage the disease and focus on cessation of smoking (fried et al., 2012).

  • Lifestyle changes can improve tissue perfusion (Bernard et al., 2010)


  • Proper knowledge of self-management of disease and motivation to quit smoking 
  • Detailed knowledge about the things to be avoided and ensuring a healthy lifestyle
  • Knowledge about handling an episode of acute attack



Task 3

It is important for Laura to adhere to prescribed medication and patient and her family members understand the reason and correct use of the medication. There must be an adequate understanding of the illness, its triggers, signs and symptoms and when to seek medical attention making it important for Laura and her family members to adhere to care instructions (Creer, 2010).

Two important points to include in Laura’s preparation for discharge includes self-care management and focus on short as well as long-term health care and lifestyle change goals. This is so as self-management is most important among asthma patient as they suffer anxiety and depression more than the general public. It is important for such patients to look for strategies where they can recognize the way their own behavior, habits and lifestyle affect their thoughts and feelings (Fried et al., 2012). Such an understanding may help people with asthma and bronchitis better cope with their condition and reduce the changes of hospitalization. 

An important aspect of controlling asthma and acute bronchitis risk factors is lifestyle modifications. Laura has been provided with culturally appropriate knowledge throughout her stay at the hospital along with the strict changes required in her lifestyle. Smoking and alcohol abuse being the leading preventable cause of mortality and morbidity (Fried et al., 2012), it is important that Laura focus on quitting these habits and adopt a heathy lifestyle while focusing on losing some good amount of weight. Smoking cessation will have multiple benefits on her heath as its linked strongly with asthma as well as diabetes and hyperlipidemia

Self-care management needs Laura to understand and ensure the importance of taking her new as usual prescribed medications while remaining successful in controlling the environment she lives in and avoiding smoking and alcohol abuse. This can be done by using lifestyle modification strategy by listing the triggers and habits. Identifying patterns will help the patient to identify when she is most likely need support or distraction from smoking and alcohol. 

It is the black -box theory that guides asthma self-management with an emphasis on input (independent variables) and output i.e. dependent variables (Creer, 2010). However, in case of Laura it is important to pay more attention to behavioral processes that occurs between this basic process of input and output. Therefore, following a cognitive strategy to help patient and her family adhere with short-term and long-term health goals will help Laura to implement the education into her daily routine. This will help her to define goals and achieve them without any risk of anxiety and depression and improving medication adherence (Kew et al., 2016).

Task 4 

A new medication Prednisolone 25mg OD PO is prescribed to Laura for management of her acute condition of bronchitis. It is to be noted that the goal of treating acute bronchitis is focused on decreasing the inflammation where short term steroid therapy proves to be helpful in reversing inflammation and dilation of the bronchial tubes (Fayyaz and Mosenifar, 2019). Prednisolone is one such medication that will enhance the anti-inflammation effect of the steroids produced within the patient’s body by the adrenal glands making it an effective prescription for Laura. 

Laura has been prescribed this medicine to control the serious and worsening of bronchitis symptoms resulting in wheeze and chest pain while breathing. As it is a systematic anti-inflammatory steroid, Prednisolone help in reducing airway inflammation, swelling, mucus production and breathlessness being much more potent than cortisol to suppressing the immune system. 

However, it is important to look for certain side effects in the form of high blood pressure and fluid retention. Also it can elevate blood sugar levels which is a key point to monitor as Laura reported of TsDM. 

Laura is usually on Ipratropium bromide MDI 21mcg INH, which is a short-acting antimuscarinic agent for maintaining the treatment of asthma. In Australia it is used frequently as it proved to be safe with little changes of any nausea or vomiting when INH is administered (Powell and Cranswick, 2015). It works by relaxing and opening of air passages to the lungs making breathing easy for the patient suffering from bronchitis, and asthma. The symptoms may be visible in the form of wheezing and shortness of breath, which is evident in case of Laura with a history of asthma. The medication works by relaxing the muscles around the airways making it easy for the user to breathe and decrease the comfort during episodes of asthma attack (Donohue et al., 2016).

Laura has been prescribed this medication because of her history of asthma where the cholinergic nerves going to the lungs cause narrowing of the airways through stimulation of the muscles present around the airways to contract making breathing difficult for the individual. She needs a breathing aid in the form of INH allowing her to breathe properly. 

However, there are possibilities of certain side effects in the form of chest pain, dyspnoea, palpitations and urinary retention. Laura already reported the history of dyspnoea that may be due to this medication.