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Assessment of Infection, Blood Pressure, and Insufficient Breathing in Jim


Discuss about the Medical Surgical Nursing and Care Of Jim.

In medical surgical nursing, assessment of the patient is the most crucial step because suitable treatment can be planned based on the assessment. Based on the provided information infection, breathing insufficiency and blood pressure need to be assessed in Jim. Recorded blood pressure for Jim is 158/86. This blood pressure is much higher than normal blood pressure which is 120/80. Sphygmomanometer is useful in measuring blood pressure for its assessment. Moreover, he is having habit of smoking and smoking can exaggerate hypertension.

In infected patients, there are the chances of increase in white blood cells (WBC) count. Hence, for assessment of infection, WBC need to be counted in Jim. Infected organism can be identified by culturing samples like sputum and nasal discharge. Sputum and nasal discharge samples need to be evaluated in Jim because he is diagnosed with influenza virus and can produce infection in the respiratory system. Due to infection of respiratory system, there are chances of insufficient breathing in Jim. Assessment of insufficient breathing can be performed by measuring respiratory rate and oxygen saturation level. Moreover, breathing pattern can also be assessed in Jim (Timby and Smith , 2013; Dewit et al., 2016).

Assessment of infection, blood pressure and insufficient breathing is necessary in Jim because it can be helpful in planning treatment plan for him. Identification of infected organism is required because specific antibiotic can be given based on the identification of organism. It is necessary to give specific antibiotic because other antibiotics can not prevent growth of infected organism. Infection of the respiratory tract can result in dysfunction of respiratory tract hence insufficient breathing can occur in Jim. Insufficient breathing can lead to lowered level of blood oxygen. To compensate this, heart need to pump at faster rate which results in hypertension in him. Since, all these conditions can affect each other. It can result in multiple organ deterioration in him, hence infection, blood pressure and breathing insufficiency need to assessed in him (Berman, et al., 2014).

Nursing Care Plan: Jim

Nursing problem: Risk of spread of infection

Underlying cause or reason: Influenza  is a highly contagious virus spread via airborne droplets and direct contact. Immunocompromised patients in the hospital setting are at higher risk of contracting disease resulting in adverse events.

Goal of care

Nursing  interventions/actions


Indicators your plan is working

To prevent and control the spread of influenza within the healthcare facility and the community.

Assess infection risk by culturing sputum and nasal secretion samples. 

Count WBC.

Ensure patient is using face mask at the time of cough and sneeze.

Educate patient and ensure that patient practicing hand washing with appropriate antiseptic and decontaminating articles used by him. 

Educate patient about wearing gown and gloves and ensure that patient is wearing it.

Provide isolated environment for the patient until infection persists.

Consult with doctor and administer appropriate antibiotic.

Early assessment of the infection can be helpful in planning effective nursing plan for the patient (Carpenito, 2013).

In patients with infection, there is possibility of raised WBC count (Lemone et al., 2017)

Mask can prevent spread of infection during coughing and sneezing (Li et al., 2014)

Washing hands with antiseptic and decontaminating articles used by patient can kill influenza virus, hence its spread can be prevented (Patel et al., 2014; Manfredi and D'Onofrio, 2013).

Gown and gloves can prevent spread of infection (Patel et al., 2014; Manfredi and D'Onofrio, 2013).

Isolated environment can prevent spread of infection to another susceptible person (Patel et al., 2014; Manfredi and D'Onofrio, 2013)

Antibiotic can kill infected virus or prevent its spread (Patel et al., 2014; Manfredi and D'Onofrio, 2013).

Absence of virus in the sputum sample.

Absence of symptoms related to infection.

Nursing problem: Self care deficit

Underlying cause or reason: Fatigue due to dyspnoea

Goal of care

Nursing interventions/actions


Indicators your plan is working

To encourage Jim to perform activities of daily living like bathing, clothing, eating etc.

Assess capacity of patient to perform activities of daily living.

Provide walker and other assistance devices to the patient.

Provide support and assistance to carry out activities.

Provide isolated environment, hence there would not be stigma of shame while performing activities.

Encourage patient to perform activities on his will without putting any sort of pressure.

Ensure family members to assist patient in performing activities. 

Early assessment can be helpful in planning intervention to improve patient’s activities (Gulanick and and Myers, 2016).

Patient can perform activities with ease (Seed and Torkelson, 2012).

Self-esteem and dignity of the patient can be maintained (Seed and Torkelson, 2012).

Minimal assistance required for Jim to perform his activities.

Nursing problem: Risk of imbalanced fluid volume

Underlying cause or reason: Inadequate and un-scheduled diet and fluid intake. Loss fluid due to vomiting as a result of consumption of medicines.

Goal of care

Nursing interventions/actions


Indicators your plan is working

To maintain sufficient hydration in the patient.

Maintain input and output chart for Jim and incorporate dietician to monitor this chart.

Measure body weight on daily basis.

Measure vital signs like blood pressure, heart rate, respiratory rate and body temperature

Assess and monitor oral mucosa and skin turgor.

Assess activity level and orientation of patient by applying Glasgow coma scale.

Accurate requirement of fluid can be assessed which can be helpful in providing optimum level of fluid (McGloin, 2015).

Imbalance in fluid intake can alter body weight.

Inadequate intake of fluid can lead to dehydration and alteration in homeostasis which can produce tachypnoea, hypotension and tachycardia due changes in the cardiovascular and respiratory parameters (McGloin, 2015).

Oral mucosa and skin turgor indicates dryness indicate dehydration which can occur due to imbalance fluid intake (McGloin, 2015).

Imbalanced fluid intake can result in altered electrolyte balance. It can lead to altered orientation in the patient (McGloin, 2015).

Jim started optimum amount of fluid according to the need of the body.

 Normal oral mucosa and skin turgor.

Nursing problem: Risk of constipation

Underlying cause or reason: Inadequate consumption of solid diet and liquid fluid.

Goal of care

Nursing interventions/actions


Indicators your plan is working

Confirm that Jim get respite from distress during defecation

Determine stool consistency and frequency of defecation.

Encourage and ensure patient is drinking plenty of warm water.

Encourage and ensure patient to consume adequate amount of food.

Consult with physician and administer bulk laxative.

Include dietician and nutritionist in his care.

Abnormality in defecation can be assessed by determining stool consistency and defecation frequency (Costilla and  Foxx-Orenstein, 2014).

It can be helpful in ensuring normal defecation in patient (Costilla and  Foxx-Orenstein, 2014).

Laxatives can relive patient from constipation and maintain normal elimination (Costilla and  Foxx-Orenstein, 2014).

Fluid diet can make stools soft and solid fluid can improve stool consistency (Costilla and  Foxx-Orenstein, 2014).

Normal defecation.

Normal elimination and well-formed stools.

No distress during defecation for Jim.

Nursing problem: Activity intolerance

Underlying cause or reason: Weakness and fatigue due to dyspnea

Goal of care

Nursing interventions/actions


Indicators your plan is working

Ensure Jim is performing activities of daily living normally and reduces risk of respiratory insufficiency.

Assess vital signs before the start of activity and after completion of activity and compare alteration in activities due to activities.

Encourage and ensure patient to take rest in frequent intervals and within the activities.

Provide artificial oxygen to the patient after consultation with doctor.

Provide emotional support to the patient to improve his morale.

Assessment in the alteration in the vital signs can be helpful in assessing deterioration of the different organs (Doenges et al., 2016; Yates et al., 2014)

Stress for the completion of activities can be reduced and risk of fall can also be reduced (Doenges et al., 2016; Yates et al., 2014)

Energy can be restored and fatigue can be reduced by taking frequent rest periods (Doenges et al., 2016; Yates et al., 2014)

Breathing rate and breathing pattern can be improved and risk of fatigue can be reduced (Chlan et al., 2015)

Self-confidence for the completion of activities can be improved through emotional support (Potter et al., 2013)

Jim is performing activities of daily living without stress and devoid of fatigue with improved breathing pattern.

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


Indicators your plan is working

To encourage Jim to express his depression and anxiety.

Assess and monitor severity of depression and anxiety.

Identify physical response to anxiety. Encourage patient to verbalize about depression and anxiety.

Educate patient about depression and anxiety and provide counselling related to it.

Assessment and monitoring can be helpful in planning effective intervention (Gulanick and Myers, 2016)

Most of the depression and anxiety patients are not willing to express or verbalize it. Hence, it can be helpful in recognising the condition and providing suitable intervention (Gulanick and Myers, 2016).

Stress related to depression and anxiety can be effectively reduced by providing education and counselling (Gulanick and Myers, 2016).

No signs and symptoms of depression and anxiety in Jim.

Jim verbalised and expressed depression and anxiety.


Oseltamivir (75mg orally bd) is effective against both Influenza A and Influenza B viruses. Nurse should monitor symptoms of influenza like sudden onset of fever, cough, headache, fatigue, muscular weakness and sore throat in Jim. Assessing these symptoms can be helpful in assessing effectiveness of oseltamivir. In case of ineffectiveness of oseltamivir in Jim, nurse should consult with doctor for changing dose or frequency of oseltamivir administration. It is evident that, oseltamivir can produce psychological disturbance and behavioural changes in the patient. Hence, nurse need to assess these psychological disturbances in Jim (Skidmore-Roth , 2017; Tiziani, 2013).

Paracetamol (4/24 orally prn) is a drug which is useful for treatment of fever and pain. Provided data indicate that Jim is having fever. Post administration of paracetamol, nurse need to record body temperature in frequent intervals in Jim. If the is no reduction in the body temperature in Jim in first 48 hours, nurse need to consult doctor for changing dose and frequency of paracetamol administration. It is advisable not to consume paracetamol on empty stomach. Hence, nurse should ensure that Jim is consuming paracetamol after consuming optimum diet. From the literature, it is evident that paracetamol can produce liver toxicity. Hence, nurse should discuss with clinical biochemist and perform liver function test in Jim (Skidmore-Roth, 2017;  Tiziani, 2013).

Goal of Care: Prevent and Control the Spread of Infection

Influenza infection can be controlled by consuming Fluvax (IM stat dose). Nurse should ensure that Fluvax is being administered every year because it is effective preventive strategy for influenza. One year is the optimum duration for the administration of Fluvax because antibodies in this vaccine can exhibit effect upto 10 months. Fluvax can exaggerate the hypersensitivity of egg and other components of vaccine. Hence, nurse need to check hypersensitivity of these in Jim prior to administration of Fluvax (Skidmore-Roth , 2017; Tiziani, 2013).

Transmission of influenza virus through coughing and sneezing occurs by direct mode. Susceptible people can get infected through sneezing and coughing. Transmission through hands transfer and transmission through articles used by patient can occur through indirect mode. Nurse should educate Jim about both modes of transmission and teach him techniques to prevent these transmissions. Jim should be informed by nurse that he should wear mask while coughing and sneezing. Hand transmission of the virus from Jim can be prevented by washing the hands with suitable antiseptic. Moreover, articles used by Jim also can be decontaminated by using appropriate antiseptic solution. In addition to this nurse should make him aware about signs and symptoms of influenza infection. Hence, he can recognize it and inform to nurse. So that, nurse can make appropriate care plan for him. It is important for Jim to prevent infection because it can affect functioning of other organs like lung and heart. Due to infection there can be insufficient breathing and hypertension in him (Morton and Fontaine, 2017). Nurse can evaluate understanding of Jim about infection prevention by observing his infection prevention activities like use of mask and washing of hands with antiseptic. For the prevention of spread of infection, Jim should use mask, gloves and gown. He should not visit crowded places (Jardins and Burton, 2015). 

In this case, there is alteration in the breathing pattern mainly due to respiratory infection of influenza virus. As a result, there is reduced oxygen level due to decreased gaseous exchange at alveoli wall and capillary wall interface. It indicates deterioration of the respiratory system.  Due to reduced level of oxygen, heart start pumping at the faster rate. Hence, there is increased heart rate and blood pressure. Due to abnormality in all these vital signs, fever occurs in Jim and he is also experiencing shivering (Blanco eta l., 2010).

As an immediate care action, Jim need to be provided with artificial oxygen which can improve his oxygen saturation level and consequently breathing pattern and breathing rate. Improvement in these respiratory parameters can improve his heart rate and blood pressure. Medications for hypertension and fever need to be administered to Jim. These early actions can be helpful in improvement of vital signs like blood pressure, heart rate and respiratory rate. Improvement in these vital signs can be helpful in preventing deterioration of organs like heart and lung.

I am a nursing student in the medical-surgical ward. I am looking after patient named Jim who is infected with influenza A virus. After providing treatment for 48 hours, he exhibited improvement. Despite this, in the morning he exhibited fever and shivering. He also exhibited abnormality in breathing and reduced response to speech. There is alteration in the vital signs of Jim. His recorded vital signs are temperature 39.6?C, heart rate 125 bpm, respiratory rate 24 bpm, blood pressure 124/79 mm/Hg and oxygen saturation 86 %. Alert monitoring of Jim is necessary. After assessment, doctors referred Jim to high dependency department to avail BIPAP.


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