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Nursing Care Plan

Discuss about the Dehydration and pain management In Nursing.

Nurses provide care to all people in many different health care settings with all types of health care needs. This paper identifies two nursing problems specific to 25 year old, Mr Davis, who admitted following a motor vehicle accident. The care plan will be develop, person centred care model will be used to provide care to identified problems. The paper also identifies the interventions with rational and outlines the expected outcome using nursing care plan table. It is guideline for nurses to follow or maintain the care for the individual patient and is a way of communicating and organising the action or duty of a constantly changing nursing staff. Dehydration and pain management would be the main priories in the situation that the patient is presented with in the orthopaedic unit at the Townsville Hospital.

Nursing Care Plan

Nursing Problem 1

Dehydration

Nursing Goals

To Increase Mr David fluid input and output within the next 2hours and within 15minutes check the IV line that is not blocked and delivery the correct amount of dose that required.

Interventions with rational

·         Monitor vital signs – decrease urine output, increase respiratory rate, decrease circulation cause patient to become hypotension and confusion (Brown, Edwards, Seaton & Buckley, 2015).

·         Early signs of dehydration – dry lips, dry skin, headache, dizziness and constipation is to prevent kidney failure or heart problem. The kidney helps to control body temperature, decrease blood pressure and increase heart rate(Brown, Edwards, Seaton & Buckley, 2015).

·         Monitor Fluid Balance Chart – not overload the patient with extra fluid input which would cause oedema in extremities limb (Mayo Clinic, 2018).

·         Complication of dehydration – fluid loss that would have impact in kidney functions and electrolyte a balanced (Brown, Edwards, Seaton & Buckley, 2015).

·         Skin turgor – know the skin turgor is mild, moderate or severe that the fluid been lost (skin turgor, 2018).

·         IV therapy – check the correct amount for glucose saline with potassium to provide good means of meeting the routine maintenance needs (National, 2013)

·         Neurovascular assessment – ensure the leg get enough blood flow and oxygen to the rest of the body, would be looking colour, warmth, movement and capillary refill (Rachael, 2015).

·         Urinalysis – how dehydrated is the patient and check for urine tract infection (Mayo Clinic, 2018).

·         Report and document – informing all the staff member of the action, reason and outcomes (Ossenberg, Henderson& Dalton, 2015).

·         Place a sign of nil by mouth – to ensure that all the staff member is aware and notify kitchen staff.

Expected health outcomes

Patient skin colour return, warm, normal circulation volume, no UTI present, no kidney function problem and vital signs within normal range. Monitor the IV line, report and document the patient process. Normal urine output.

Nursing Care Plan                   

Nursing Problem 2

Managing the pain

Nursing Goals

Free patient for pain and decrease the pain to burley level that patient can tolerance.

Interventions with rational

·         Perform a pain assessment – to get good understanding of the pain level, severity, risks of adverse effect, correct nursing action and if the pain radiating in other place of body and redo within 30minutes of admiration of analgise or opioids drugs (Tollefson, 2016).

·         The RICE (rest, ice, compression and elevate) technique – reduce the mobility, reduce swelling and reduce future damage or complication (Ossenberg, Henderson & Dalton, 2015).

·         Document vital signs and progress notes – ensure an effective communication is done throughout the team members, report and abnormal vital signs relate to pain patient would be experiencing such as increase heart rate, blood pressure and pulse.

·         Checking medication chart – ensure that medication order meets the patient goals of reduce the pain, checking for any errors, drug name, dosage and route to reduce adverse side effects(Brown, Edwards, Seaton & Buckley, 2015).

·         Using distraction such as TV, music and Talking to the patient – would help to reduce the stress, anxiety and muscle tension which could make the pain worse. It helps the body to release natural pain relieving chemicals into the brain (university of oxford, 2014).

·         Placing the patient in quiet environment–decrease anxiety, stress and reduce pain (Paula, 2015).

·         Drug therapy – requiring from the doctor increase dose of opioid or an IV (or SC) opioid or IN fentanyl to relieve the pain (Leach, Hofmeyer & Bobridge, 2016).

·         Monitor and report any side effects – knowing the side effects is one of the reason why treatment may failure and non-adherence. This way can be treated early before causing any complication to the patient (Ryan, 2016).

·         Notify doctor - requiring the patient pain increasing and would need review for stronger pain medication (Tollefson, 2016).

Expected health outcomes

Patient pain level decrease 5/10.Patient display improvement in mood and coping. Patient display improved wellbeing such normal rage BP, RR, HR and relaxed muscle tone and body posture. 

 

In the current context, MR. David was a 25 year old man who had met with a motor vehicle accident and had been admitted to the emergency care unit of the hospital. Based upon the clinical symptoms expressed by the patient two particular nursing priorities had been chosen for the patient which were restoration of hydration in the patient along with management of pain, as the patient complained of headache , dizziness along with acute pain the limbs .  Hence, based upon the nursing priorities chosen by the nurse a care plan had been designed for the patient.

In the current study , the nurse had  followed  an evidence  based  pathway for the care and management  of the patient condition, she had designed the care plans using the  Nursing  Midwifery Board Australia (NMBA) standards.  As mentioned by Hatherley, Jennings & Cross (2016), aligning the care plans with the NMBA standards helps in the dissemination of quality support and care.

NMBA standard 3, standard 4, standard 5, standard 6 and standard 7

The intervention for Mr. David was chosen based upon the nursing standards f of practice.

As per the NMBA standard 3, the nurse here maintained a capability for practice by responding in a timely manner to the treatment and services of the patient.

As per NMBA standard 4, the nurse had comprehensively conducted assessments to analyse the current health situation of the patient. Some of the assessments approached adopted by the nurse over here was conducting the RICE assessment which could reduced the pain complications within the patient. Additionally, the neurovascular assessment helps in monitoring vital signs such as the presence of sensation in the legs of the patient (Brown, Edwards, Seaton & Buckley, 2017). In case, the patient shows reduced sensations or reduce leg movements, physiotherapy sessions could be introduced for the patient.

Nursing Problem 1 - Dehydration

As per standard 5 of the NMBA standards, the nurse had used assessment data for the planning and d designing if effective cares plan.

As per standard 6 of the NMBA standards, the nurse provides safe, appropriate and quality nursing practice. The nurse here uses RICE assessment test to reduce the chances of future complications arising out of the injury.

As per standard 7 of the NMBA standards, the nurse had used effective documentation to communicate nursing priorities, goals and outcomes.

Conclusion

The pathway which had been chosen by the nurse over here was to monitor the vital signs of the patient for dehydration and follow up with the fluid input and output   every two hours.  The process selected by the nurse over here was maintaining a fluid balance chart. For the pain management, the patient was put on a constant opoid supply, where fentanyl had been provided to the nurse of reducing the amount of pain experienced by the patient. It was administered thought the type IV channel.  Additionally, the RICE assessment had been used to reduce the future complications within the patient arising from the damage. The nurses also followed a standard assessment pathway for monitoring the mood and well being of the patient by providing them with relaxations such as watching television or music therapy.   The nurse also had to ensure that the drug had been administered to the patient in safe doses, as overdose of the drug could   result in severe health consequences.

Therefore, following and evidence based pathway helps in ensuring that safe and effective nursing care services are provide to the patients. The nursing standards help in, maintaining a step-by step approach to the clinical care. Therefore, it reduced the chances of missing out the important steps which are vital to the recuperation of the patient. It is the duty of the nursing professional to reduce the pain within the patient by using relaxation and mood uplifting techniques. However, the nurse could have followed effective pain management techniques for controlling the level of pain experienced by the patient. For example, using assessment tools and metrics such as Braden scale could have helped the nurse in measuring the progress of r pain reduction in the patient more accurately.

Therefore, the implementation of the NMBA standards also help in ensuring that the patient is  given sufficient autonomy in deciding  over the course of his care plan.  This helps in implementing a person centred approach where care and   complete recuperation of the patient are placed at the core.

Reference list

Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2015). Lewis's medical-surgical nursing: Assessment and management of clinical problems (Fourth ed.). Chatswood, N.S.W: Elsevier Australia.

Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2017). Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Amsterdam: Elsevier Health Sciences.

Hatherley, C., Jennings, N., & Cross, R. (2016). Time to analgesia and pain score documentation best practice standards for the Emergency Department–A literature review. Australasian Emergency Nursing Journal, 19(1), 26-36.

Leach, M. J., Hofmeyer, A., & Bobridge, A. (2016). The impact of research education on student nurse attitude, skill and uptake of evidence?based practice: a descriptive longitudinal survey. Journal of clinical nursing, 25(1-2), 194-203.

Mayo clinic, 2018, Dehydration. Retrieved 20 April, 2018 from https://www.mayoclinic.org/diseases-conditions/dehydration/symptoms-causes/syc-20354086

Medline Plus, 2018. Skin turgor. Retrieved 20 April, 2018 from https://medlineplus.gov/ency/article/003281.htm

Nathional, (2013). Principles and protocols for intravenous fluid therapy.Retrieved 20 April, 2018, from https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0082773/

Ossenberg, C., Henderson, A., & Dalton, M. (2015). Determining attainment of nursing standards: the use of behavioural cues to enhance clarity and transparency in student clinical assessment. Nurse education today, 35(1), 12-15.

Rachael, S. (2015). Neurovascular observations. Retrieved 20 April, 2018 from https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neurovascular_observations/

Ryan, E. J. (2016). Undergraduate nursing students’ attitudes and use of research and evidence?based practice–an integrative literature review. Journal of clinical nursing, 25(11-12), 1548-1556.

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