NUR251 Assessment 1 S2 2017 Assignment, Nursing Care Plan (Essay Sample)

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NUR251 Assessment 1 S2 2017 Assignment

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Task 1
Monitor the vital signs: blood pressure, temperature, respiration rate, SPO2 levels and the heart rate. Note them on the observation chart. The vital signs are the fastest means to detect a complication like infection and shock therefore it is important to note any deviations from normal. Secondly, maintain a special chart to monitor number of soaked perineal pads to monitor the vaginal bleeding. Monitor the pads for colour, odour and clots. The special chart will therefore allow nurses determine excessive bleeding which is a sign of complication. Early detection of complication allows for early management and correction. Thirdly, maintain a fluid input-output chart to monitor the fluid balance and detect signs of fluid imbalance. The fluid chart helps evaluate the amount of transfused fluids. It is also crucial in determining the time at which a fluid was commenced hence allow for correct drop regulation. Voiding monitoring is also via the fluid chart hence determination of the amount the patient has lost allowing calculation of the fluid balance. Always ensure clear documentation of any procedure to avoid missing or repetition and for reference purpose (Nelson, G., et al, 2016).
Post hysterectomy, Jane demands bed rest, constant monitoring of the bleeding, adequate pain management and intravenous fluids. Ensure pain management as per instructions from the medical team. Maintenance of pain evaluation to ensure the pain is adequately minimized (Journal of mid-life health, 2016). Position the patient avoiding pressure on the operation site. Prop-up the bed to 45 degrees to ensure adequate airway opening and facilitate venous return. Inadequate documentation may lead to under or over dosage (Lemone et.al, 2017).
Task 2
Nursing Care Plan: Jane Doe
Nursing problem: acute pain

Related to: hysterectomy

Goal of care

Nursing interventions

Rationale

Evaluation

Relieve pain

* Administer analgesics per the medical team’s instructions.
* Avoid pressure on the operation site.

* Analgesics block the pain detecting nerves in the central nervous system.
* Pressure on the operation site (Lemone et.al, 2017).

* Oral Paracetamol 1g QID, IM Ketorolac 30mg , oral Methadone 30mg, oral Tramadol 100mg, IM Fentanyl 100mcg administered per the instructions.
*

Nursing problem: anxiety

Related to: loss of femininity, cervical cancer diagnosis

Goal of care

Nursing interventions

Rationale

Evaluation

Allay anxiety

* Provide psychological support through counselling
* Provide contact with a local support group
* Advice her to identify an individual to support her during discharge

* Creates a sense of reassurance
* Helps with the grieving process via sharing similar experiences and advice on coping mechanisms
* To ensure physical and emotional support (Lemone et.al, 2017).

* Patient psychologically stable
* A local support group for patients who underwent hysterectomy contacted
* Jane left to decide on her choice of support person

Nursing problem: disturbed body image

Related to: fear of sexual relationship with partner, altered fertility

Goal of care

Nursing interventions

Rationale

Evaluation

Improving the body image

* Counsel on gradual return to sexual activities following discharge
* Explain changes in hormones
* Advice for counselling with the partner

* Initially, sexual intercourse maybe painful and uncomfortable
* The change may cause reduced libido
* To promote understanding by the partner hence allow for support (Lemone et.al, 2017).

* Jane verbally acknowledges the importance of slow return to sexual activities
* She verbally demonstrate understanding
* Awaits her consent to invite partner

Nursing problem: knowledge deficit

Related to: unsure of the surgery outcome, spread of cancer cells to neighbouring organs

Goal of care

Nursing interventions

Rationale

Evaluation

Prevent knowledge deficit

* Provide patient with efficient information on the outcome and possible complications
* Involve her during care
* Explain possible complications with the signs and symptoms
* Identify long-term effects of hysterectomy like complete loss of infertility

* Help her understand the health facts following her diagnosis and prognosis
* Enable her comprehend the process and rationale of each plan of care
* Allow early detection therefore appropriate management
* Enable her identify and prepare with coping mechanisms (Lemone et.al, 2017).

* Patient verbalizes a better understanding of the diagnosis and prognosis of hysterectomy
* Patient allowed to participate during plan of her care
* Patient verbalizes understanding of signs and symptoms of possible complications
* Patient demonstrates awareness of loss of fertility

Nursing problem: risk for infection

Related to: presence of operation wound

Goal of care

Nursing interventions

Rationale

Evaluation

Prevent infection

* Maintain the wound dressing intact and clean
* Monitor the colour and odour or any discharge from the wound
* Administer prophylaxis antibiotics
* Practice infection-prevention techniques like hand washing and use of gloves during patient handling by nurses
* Change soaked pads and clean vagina
* Assess the vital signs from deviating from normal
* Remove Foley catheter post operatively day 2 or per the medical team’s instructions

* To prevent entry of microorganisms to the wound.
* Detect signs of infection via purulent discharge
* Antibiotics kills and prevent multiplication of infection causing microorganisms
* Prevents transfer of microorganisms across surfaces and patients
* High temperatures greater than 100.5 F, reduced respiration rate, elevated heart rate and a low blood pressure indicates presence of infection
* To prevent leaking that creates microorganisms thriving environment (Lemone et.al, 2017).

* Dressing intact and clean
* No discharge from the wound
* 1 gram of ceftriaxone given intravenously
* Infection-prevention techniques maintained
Vital signs monitored every 4hours
Foley catheter to be removed day 2 postoperatively

Nursing problem: risk for fluid volume imbalance

Related to: blood loss during surgery

Goal of care

Nursing interventions

Rationale

Evaluation

Prevent fluid volume imbalance

* Administration of intravenous fluids
* Monitor vaginal bleeding through noting soaked pads

* Body fluids are lost during surgery hence important in maintenance of homeostasis and wound healing post surgery. The patient is on nil per oral therefore fluid balance is achieved intravenously.
* Each soaked pad helps estimate the amount of blood loss (Lemone et.al, 2017)

* Sodium chloride 1000 mls administered over 8 hours intravenously

Nursing problem: risk for deep venous thrombosis

Related to: immobility following anaesthesia

Goal of care

Nursing interventions

Rationale

Evaluation

Prevent deep venous thrombosis

* Mobilize the patient
* Low molecular weight heparin anti-coagulants administration
* TED stockings
* Discourage prolonged sitting or standing

* Early mobilization of the patient helps
* Low molecular weight heparin anti coagulants inactivates thrombin.
* TED stockings create compression therapy that prevent venous stasis and improve blood flow.
* To prevent venous stasis (Lemone et.al, 2017)

* Patient mobilized as soon as anaesthesia wears off.
* Escitalopram 20mg administered.
* TED stockings provided
* Jane verbally explains understanding of the risks for prolonged standing or sitting

Task 3
Postoperative pain management is aimed to reduce or eliminate pain following the surgery. Pain relief plays an important role in promoting the psychological wellbeing of the patient. Multiple analgesics are use simultaneously to minimize side effects and improve the pain score. Poor management of pain has repeatedly been associated with slow recovery, high incidence of complications and lengthened rehabilitation(BHATTI, T., 2008).
During administration of analgesics, nurses should pay attention to the five rights of a patient: right drug, right dosage, right patient, and right route and at the time. The nurse should assess her pain score repeatedly and routinely to evaluate the effectiveness of the analgesics. The nurse trains the patient to rate the pain on a scale of 0 to 10 with 0 meaning no pain and 10 symbolizing extreme possible pain. Following the routine assessment of pain, the nurse is able to adequately evaluate patient’s satisfaction with the pain management (Tiziani, 2013).
The nurse trains Jane on the signs and symptoms of possible side effects of the administered analgesics. In presence of side effects or adverse effects, the nurse should efficiently manage to minimize complications and promote patient’s comfort. However, other drugs may be given simultaneously with analgesics to prevent the occurrence of side effects. Anti-emetics like metroclopramide to curb nausea and vomiting. The nurse should be able to identify the patient’s tolerance and addiction tendencies to the drugs. Some drugs like methadone has addiction tendencies therefore usage and cessation are controlled (White, PF,1995).Bottom of Form
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