1. 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. Why the assessment is relevant to Jim’s care.
2. What consequences may occur if this assessment is not completed accurately?
Initial Assessment
Initial assessment that covers patient’s history, vital signs and a head to toe physical examination. It helps to confirm the symptoms verbalized by the patient. This assessment will help in identifying the aetiology of Jim’s condition, any underlying conditions, duration of the symptoms and severity (Wahlin, Lindström, Ponzer, & Vicente, 2018). It helps in prioritizing plan of care for Jim and identifying the root cause of the condition. In case this assessment is not well completed, Jim’s care will not be prioritized and facts such as the contagious nature of the disease might be missed. The symptoms might be missed leading to exacerbation of the condition leading to fatal complications.
Focused assessment where diagnosis is made and treatment is given under supervision (DeMaria, Twist & Weeks, 2017). In this assessment, vital signs are monitored regularly as they point out how Jim is fairing on. This assessment helps in eliminating the differential diagnosis that may present with similar symptoms of dyspnoea, myalgia, headache, rhinorrhoea and malaise as Jim’s and point out the main diagnosis to enable monitoring the progress under treatment to ensure stability of the patient. In case this assessment is not completed; the primary diagnosis might be missed and the patient will be managed for a wrong condition.
Time-lapsed assessment is conducted as medications are being administered to find out the patient’s progress. It starts after a few hours and will continue as long as the patient is admitted. The conditioned is assessed in comparison with the original state to identify the change (Cattoli, Trkov & Capote, 2016). Jim will be monitored for any adverse effects of the medication and whether the medication is working. In case the dyspnea, headaches and rhinorrhoea do not resolve with treatment, the patient is reassessed and replanning done. Failure to complete this assessment can lead to patient having unnoticed adverse drug reactions and the condition may be worsening without attempt to manage it well.
Nursing Care Plan: Jim
Note: Dot points recommended in care plan. Click and type in each cell, click enter in a cell to make it longer. Do not remove text from the template.
A reminder that all rationales must be referenced
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Nursing problem: Risk of spread of infection |
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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. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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To prevent and control the spread of influenza within the healthcare facility and the community. |
· Administer oseltamivir 75mg Bd · Wearing of masks and gloves before coming into contact with the patient. · Proper handwashing before and after coming in contact with the patient. |
· Oseltamivir is an antiviral drug against influenza virus. It has the ability to clear an influenza infection hence rendering Jim noncontagious (Dobson, Whitley, Pocock & Monto, 2015). · Influenza is transmitted through respiratory droplets or by contact with infected surfaces. Wearing masks and gloves reduces chance of contracting or spreading (Varble, Albrecht, Backes, Crumiller, Bouvier, Sachs, & García-Sastre, 2014) · It helps in reducing cross contamination (Little, Stuart, Hobbs, Moore, Barnett, Popoola ... & Yao, 2015) |
· Jim’s symptoms of rhinorrhoea, malaise, dyspnoea subsides. |
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Nursing problem: Self-care deficit |
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Underlying cause or reason: influenza virus presents with symptoms of malaise and fatigue. This reduces the ability of the patient to take care of himself and perform daily activities of bathing, walking, and going to the toilet. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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To help Jim perform selfcare activities such as bathing, walking, going to the toilet and dress. |
· Provide support to the patient when walking and encourage him to walk. · Educate patient on the importance of independence and assist where necessary. · Establish guidelines and goals of activity with the patient. · Ensure Jim performs activities of daily living according to his ability. · Provide a conducive environment to enable Jim perform selfcare, e.g. a clean place to brush teeth. |
· Minimum support and education encourages patient for self-care (Fivecoat, Sayers & Riegel, 2018) · Enhances motivation and self-esteem of the patient (Stamp, Dunbar, Clark, Reilly, Gary, Higgins, & Ryan, 2016) · This increases self-worthiness and independence hence achieving the objective of self-care (Frost, Weingarden, Zeilig, Nota, & Rand, 2015). |
· Jim is able to perform daily activities with little or no assistance. · Jim dresses himself well. · Jim is well kempt and clean. |
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Nursing problem: Risk of imbalanced fluid volume |
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Underlying cause or reason: nausea and vomiting, side effects of oseltamivir Jim is taking and increased metabolism due to fever and the infection. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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· To ensure Jim demonstrates normal hydration status. · To ensure Jim has a normal heart rate that ranges between 60-100 beats/min |
· Maintain input and output fluid chart of the patient. · Monitor heartrate and blood pressure. · Monitor urine output and report when it is less than 30 mls/ hour. · Administer métoclopramide 10mg IV tds. |
· It helps identify the hydration status of the body and fluid requirement (Jeyapala, Gerth, Patel, & Syed, 2015) · Heartrate and blood pressure are the indicators of fluid imbalance and show the severity of the deficit (Hall, 2015). · It helps tell when the patient is dehydrated and requires more fluid intake when the output is less than 30mls/hour (Leedahl, Frazee, Schramm, Dierkhising, Bergstralh, Chawla, & Kashani, 2014). · Metoclopramide is a D2 receptor antagonist and speeds up peristalsis reducing vomiting (Ong & Felice, 2017). |
· Jim demonstrates a normal heartrate ranging between 60-100 beats/min. · A urine output of more than 30mls/hour is attained. · Jim demonstrates reduced feeling of nausea and vomiting after medication |
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Nursing problem: Ineffective Breathing Pattern |
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Underlying cause or reason: influenza virus infects the upper and lower respiratory tract, this can lead to inflammation hence irritation and congestion of the airways leading to shortness of breath. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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· To ensure Jim demonstrates normal respiratory rate and pattern. · To ensure Jim demonstrates an oxygen saturation of above 95% |
· Assess vital signs, respiratory rate, pattern and rhythm. · Administer supplemental oxygen 2L/min. · Take pulse oximetry readings and note when the reading is less than 90%. · Assess for abnormal breath sounds. |
· Vital signs are the baseline indicators for any condition and they give insight on further complication (Mok, Wang & Liaw, 2015). · Supplemental oxygen helps relieve symptoms of respiratory distress (Nishimura, 2015). · It helps determine arterial blood gas and gives a picture of tissue perfusion that can help prevent tissue ischemia (Diab, Weber& Ali, 2016). · Breath sounds help in identifying the condition and severity of respiratory compromise (Davis & Papachrisanthou, 2017) |
Jim has a respiratory rate that ranges between 12-20breaths/min and has no symptoms of shortness of breath. Jim has an oxygen saturation above 95%. No wheeze sound on auscultation |
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Nursing problem: Risk of Nicotine withdrawal |
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Underlying cause or reason: Cigarettes have nicotine as a main ingredient that causes addiction. Inability to afford cigarettes deprives the body of nicotine leading to withdrawal symptoms. |
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Goal of care |
Nursing interventions/actions |
Rationale |
Indicators your plan is working |
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To help patient control and overcome withdrawal symptoms such as insomnia, irritability, cravings, depression, restlessness and anxiety. |
· Encourage patient to participate in physical activities. · Enrol the patient to a rehabilitation group. · Administer nicotine replacement therapy. · Advice and counselling sessions for the patient. |
· Participation in physical exercise helps patient overcome the cravings of smoking as he gets preoccupied (Ussher, Taylor & Faulkner, 2014). · Rehabilitation groups will help the patient interact with people with similar struggles, share stories and be able to cope up with withdrawal symptoms (Gaalema, Cutler, Higgins, Savage, & Ades, 2015). · Nicotine replacement therapies are administered as the dose is reduced gradually to help the patient cope with smoking cessation (Rohsenow, 2017) · Counselling sessions helps patient to be able to understand the symptoms and have a high self-esteem (Kropff, Petersilka, Flemmig, Ehmke, Heuft & Schneider, 2016) |
Jim will be able to have adequate sleep. Jim will be able to tolerate the cravings of smoking. Patient is calm and able to socialise with other people. |
Jim has been given oseltamivir 75mg twice a day because it is an antiviral drug for influenza virus, as it stops the virus from multiplying and relieves symptoms of headaches, malaise and running nose (Dobson et al., 2015) The nurse should ensure Jim takes the drug after exactly 12 hours to maintain the drug concentration in the body for better action and ensure the dose is completed to avoid relapse of the flu. oseltamivir has side effects of nausea and vomiting, monitor his reaction after taking the medicine and if there are side effects, administer antiemetics. The nurse should monitor if the side effects are controlled, if they are not, consult the physician for another prescription.
Focused Assessment
Oral paracetamol is administered to Jim since it’s an analgesic used to treat mild pains. Jim has headache caused by the flu hence paracetamol to relief the ache (Mallet, Eschalier & Daulhac, 2017). The nurse should ensure the patient gets the medication when need arises and should ensure the Jim doesn’t get the medication for more than 10 days to avoid toxicity. Side effects to paracetamol are rare. The nurse should monitor patient for any unusual itchiness, rush or trouble breathing.
Fluvax start dose has been administered to Jim as a vaccine to make him immune to influenza virus. This prevents future recurrent infection (Ayoola, Sukumaran, Kumar, Gordon, Roy, Vantandoust & Karapetis, 2016). Nurse should ensure Fluvax is administered into a muscle and not a vein. Before administering the nurse should take a history whether Jim had received the vaccine recently or has eaten eggs or is on antibiotics polymyxin and neomycin, these are contraindications. The nurse should assess whether Jim is immunocompetent to avoid infecting him from the vaccine. The nurse should perform a physical assessment on Jim to identify side effects such as inflammation on the injection site, numbness or abscess formation.
Influenza virus causes an infection of the upper and lower respiratory tract that presents with symptoms of malaise, running nose, headaches, dyspnoea and fatigue (Davidson, McCabe, Crotta, Gad, Hessel, Beinke & Wack, 2016). It is transmitted via respiratory droplets from an infected person or coming in contact with infected surfaces hance regular handwashing prevents the spread of influenza virus (Yang, Mok, Peiris, & Zhong, 2015). One can transmit the infection even before showing the symptoms. Wearing masks by people infected and the ones at risk prevents being infected with the virus. Fluvax, a vaccine that prevents the contracting the vaccine is available and it is given yearly. Treatment of the individuals exposed reduces the chance of spreading the virus. The information must be given to Jim precisely that influenza virus can be a deadly condition when it complicates as it can lead to viral pneumonia or sinus infections (Blyth, Macartney, Hewagama, Senenayake, Friedman, Simpson & Cheng, 2016). Jim must take the medications and complete the dose to avoid spreading the virus and also avoid recurring in the future. Jim must be advised on the importance of getting the vaccine each year since the virus keeps mutating. This will help relief the symptoms preventing and controlling the incidence and spread of influenza.
Time-lapsed Assessment
Jim has been on medication for influenza but this morning the presenting vital signs, a high temperature 39.6 ?c, a rapid heartbeat of 125beats/min and a high respiratory rate of 24breaths/per min. he is sleeping on and off, diaphoretic, shivering, complains of feeling cold, restless and curled in bed, has a laboured breathing and is slow to respond when called upon. Jim has developed withdrawal symptoms of nicotine since he has a habit of smoking up to 10 packets per a day. Such a situation is considered emergency as the patient cannot tolerate the symptoms. Reassure the patient to ensure calmness. Encourage the patient to get out of bed and perform activities to relieve the cravings of cigarrete. Administer supplemental oxygen to prevent respiratory complications. Administer nicotine supplements reducing the dosage till the patient can tolerate.
I am a registered nurse from medical surgical ward. I have been taking care of Jim who is 58 years old. He was admitted with symptoms of myalgia, fatigue, dyspnea, headache and rhinorrhoea. On examination he was found to have shortness of health, soreness of the muscle and febrile. He has a history of smoking and was diagnosed with asymptomatic hypertension with no treatment. A primary diagnosis of influenza was confirmed. He has been on oseltamivir, paracetamol and had a stat dose of Fluvax. He is allergic to chicken. The symptoms had decreased till today morning when he appeared unsettled, refusing to get out of bed and complaining of cold. On examination, he presented with tachycardia 125beats/min, low oxygen saturation of 86%, a fever of 39.6 ?c and tachypnoea, 24breaths/min. He is on supplemental oxygen via face mask 2L/min as prescribed and medication have been administered and are to be continued. Close monitoring is required to assess his progress. He has been reviewed by the doctors and advised to continue with management and rest.
References
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Cattoli, G., Trkov, A., & Capote, R. (2016). Avian influenza viruses at the animal human interface: Progress and challenges in under resourced countries. International Journal of Infectious Diseases, 53, 24.
Davidson, S., McCabe, T. M., Crotta, S., Gad, H. H., Hessel, E. M., Beinke, S., ... & Wack, A. (2016). IFNλ is a potent anti?influenza therapeutic without the inflammatory side effects of IFNα treatment. EMBO molecular medicine, 8(9), 1099-1112.
Nursing Care Plan: Jim
Davis, R. L., & Papachrisanthou, M. L. (2017). Asymmetrical Breath Sounds During Respiratory Syncytial Virus Season. The Journal for Nurse Practitioners, 13(5), e255-e257.
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Diab, M. K., Weber, W. M., & Al-Ali, A. (2016). U.S. Patent No. 9,351,673. Washington, DC: U.S. Patent and Trademark Office.
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Kropff, B., Petersilka, G., Flemmig, T., Ehmke, B., Heuft, G., & Schneider, G. (2016). Success of a smoking cessation programme in smoking behaviour of chronic periodontitis patients and identification of predictors of motivation for smoking cessation–A pilot study. International journal of dental hygiene, 14(3), 168-177.
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