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Hlten503B Contribute to Client Assessment and Developing Nursing Care Plans

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Implement and monitor nursing care for clients with acute health problems.
Contribute to complex nursing care of clients. Administer and monitor medications. Administer and monitor IV meds.

Assessment 2

Post-op Case Study

Assessment 2

Question 1.
Identify a minimum of 5 nursing actions, in order of priority you would perform related to above information.
Mrs Abu has had a considerable change in her vital signs (blood pressure lowered, her pulse is rapid, her respirations increased and temperature has dropped) form the baseline taken before surgery. These findings alone would be reported to the Registered Nurse and monitored. But because of the changes in vital sings, coupled with Mrs Abu reporting light-headedness and nausea, plus her significant blood loss form the surgical wound, you would be assessing for hypovolemic shock which can be life threatening.

As the nurse you would be seeking assistance immediately, assessing her airway, breathing and circulation. Applying oxygen, applying pressure at the surgical site and continuing to monitor (airway, breathing, circulation) and vital signs until help arrives. Mrs Abu should be given nil by mouth as she may return to surgery (Gulanick, Myers, Klopp, Galanes, Gandishar & Puzas 2003, p.329).

Question 2.
Complete the interventions and rationale in Mrs Abu's care plan related to the following diagnosis
|Nursing Diagnosis |Interventions |Rationale |
|Acute pain related to tissue trauma |Assess pain-quality, severity, relieving |Used to determine clients pain and |
| |factors. |triggers |
| | | |
| |Observe and monitor signs and symptoms | |
| |related to pain- BP, pulse, and |Cognitive or behavioural differences may |
| |restlessness. |keep the client from verbalizing pain. |
| |Administer analgesic medication. |Unless contraindicated clients with acute|
| | |pain should be administered medications |
| | |on time and when indicated. |
| | |The inability to move may result in pain |
| |Change position every 2 hours and apply |and pressure and cold may decrease the |
| |ice packs as ordered |oedema and help with comfort. |
| | | |
| | | |
|Risk of peripheral neurovascular |Perform neurovascular observations as |Determines blood supply and nerve |
|dysfunction |ordered-warmth, color, pulses, sensation,|conduction past surgical site. |
| |range of motion, capillary refill. Assess| |
| |bilaterally | |
| |(Both limbs done) |Determines baseline observations to |
| | |compare. |
|Risk of infection related to diabetes and|Use of standard precautions. |Deceases the cross contamination to the |
|surgical intervention | |client. |
| |Use of aseptic technique for wound |Reduces the risk of pathogens to the |
| |dressings |surgical site. |
| | |Any increased redness, pain, and purulent|
| |Monitor for signs of infection at wound |drainage and excaudate should be |
| |site. |cultured. |
| | |These exercises reduce the secretions |
| | |staying in the lungs and bronchial tubes.|
| |Encourage coughing and deep breathing |Any signs of yellow or yellow green |
| |exercises and monitor for signs of |sputum may indicate infection. |
| |infection in respiratory system. |Adequate fluid maintains frequent bladder|
| | |empting to decrease urinary stasis, |
| | |cloudy, sediment urine may indicate |
| |Encourage fluid intake and Monitor for |infection. |
| |signs of urinary tract infection. |Uncontrolled diabetes can cause delays in|
| | |healing and lowers the immune response. |
| | | |
| | | |
| |Monitor blood sugar levels to avoid hyper| |
| |or hypoglycemias. | |
|Impaired physical mobility related to |Use analgesic before moving or movement. |Deceases in pain allow participation thus|
|pain | |better for therapy. |
| |Encourage range of motion in bed with |To long resting in bed causes muscle tone|
| |unaffected limbs |loss. |
| |Assess ability to complete activities of | |
| |daily living. |Client may need encouragement to attempt |
| |Assist as required with activities of |activities of daily living. |
| |daily living | |

(Ackley & Ladwig 2008).
Question 3. A) Using a Mims list the adverse side effects and contraindications to the IV med due at 1600 on 3/2/10.
Gentamicin has several adverse side effects; Ototoxicity (ear), nephrotoxicity (kidney/nephron) and neurotoxicity (brain) are foremost. Allergic reactions, rash and purpura (purple spots caused by blood under the skin). Superinfection is also reported; this is an infection following a previous infection, caused by microorganisms that have become resistant to the antibiotics.
Contraindications are reasons not to use gentamicin as a medication. These include any ototoxicity (toxic ear reaction) or nephrotoxicity (toxic renal reaction) previously to any aminoglycoside (MIMS Australia 2007, p.246). B) Discuss 3 nursing considerations related to the med that has been administered.
We are presuming in this answer that the medication discussed is Gentamicin. Since we have not actually administered the drug (chart is not signed off). According to the medication chart the last given medication administered is Pandadeine Forte a PRN order. The last regular medication administered is Digoxin. I have discussed Gentamicin as part B of question 3.
Gentamicin has several adverse effects that the nurse would be assessing for in Mrs Abu. These would include any previous history associated with any allergy to amino glycosides. A history of renal or hepatic (liver) compromise. Any preexisting hearing loss needs to be assessed to use as a baseline. As hearing loss is a toxic effect of this medication.
Mrs Abu would be educated to alert the nurse of any headache, dizziness, nausea or vomiting as well as hearing loss or a roaring noise in the ears. These symptoms may indicate ototoxitity. Mrs Abu would also be asked to report any skin tingle, numbness or twitching as these may indicate neurotoxicity (Tizani 2006, p.101).
Renal function would be monitored by using a fluid balance chart and Mrs Abu would be encouraged to be well hydrated to avoid nephrotoxitity, due to Mrs Abu’s age, her renal function is more than likely impaired, therefore the nurse would monitor closely (Tizani 2006, p102).
Question 4. Mrs Abu is prescribed 40mg enoxaparin daily. A) What date will the first dose be given?
The Enoxaparin is due to be administered to Mrs Abu at 0800 hrs on the 4th of February. B) Discuss why this med would be prescribed
Enoxaparin is used to prevent and treat deep vein thrombosis or pulmonary embolism (Tizani 2006, p.133).
In Mrs Abu’s case according to the medication chart it is to be used as a prophylactic deep vein thrombosis treatment. This would be due to the fact Mrs Abu’s medical history states she has a history of deep vein thrombosis following previous surgery.
Describe the site and route you would use to give this med.
The medication chart has the route for Mrs Abu to be given the enoxaparin is via a subcutaneous injection. Subcutaneous injection delivers the medication into the layer of fatty tissue directly below the skin. The abdomen (from below the costal margins to the iliac crests), the front of the thigh (about half way down and in the middle), or the fleshy back of the upper arm is all good subcutaneous injection sites (Crisp & Taylor 2007, p.863).
For Mrs Abu the nurse would assess which area is most appropriate. It should have no lesions, large muscles or bony prominences. Whichever site is chosen the nurse will rotate the site to avoid injecting in the same spot day after day. It does not matter which site you choose unless the medical officer gives specific instructions (Galan 2009).
As stated in Crisp & Taylor 2007, “the most recommended site for heparin injections is the abdomen”.
List some adverse reactions to this med.
Enoxparin is an anticoagulant; this makes haemorrhage the most prominent adverse reaction. Allergic reaction and thrombocytopenia (very low platelet count) are uncommon adverse reactions but must be considered when administering (Tizani 2006, p.133).
Question 5.
Outline the key points to be covered in Mrs Abu’s discharge and health teaching plan.
Effective discharge planning begins at the point of admission. It may even start at a pre-admission clinic. The discharge planning assessment sheet should have been assessed and completed while Mrs Abu has been in hospital. By using this document the nurse will be able to assert Mrs Abu’s needs. Communicate the details with Mrs. Abu and her family about the expected time and date of discharge to identify potential problems which may affect the discharge process (Brown & Edwards 2008, p.429).
Assess if Mrs Abu has a carer for when she returns home, for instance a family member, friend or neighbor. According to admission notes Mrs Abu lives with her daughter but we need to assess her family’s ability and willingness to assist with care. If there are concerns about mobility or safety, arrange an Occupational Therapist or Physiotherapist. Discuss the supply and use of aids and appliances, and the need for any home modifications such as, a raised toilet seat and a shower with rails. Loose carpets or electrical cords and other household hazards should be removed to avoid future falls (Health Information Publications 2010).
Confirm with the family if community nursing services are required, if so a referral and discharge plan, with information is sent to the community nursing agency. The community nurses will be available for dressings and medication assistance (Brown & Edwards 2008, p.429).
Have the correct amount of medication for Mrs Abu to take home. Check Mrs Abu and her family understand the need, amount and the time the medication is due. Medication side effects and when to contact her Doctor or hospital if a reaction occurs. Both medication effects and post surgical complications need to be explained so Mrs Abu and her family recognize changes promptly. A discussion on expected recovery and precautions to avoid hip dislocation. These include; keep your knees apart at all times, put a pillow between your legs when sleeping, never cross your legs when seated, avoid bending forward when seated in a chair, avoid bending forward to pick up an object on the floor, use a high-seated chair and a raised toilet seat, don't flex your hip to put on clothing, such as pants, stockings, socks, or shoes (Health Information Publications 2010).
Other teaching for Mrs Abu may include, Deep Vein Thrombosis prevention, it may include the use of compression stockings and an anticoagulant. Depending on the type prescribed, she may require follow-up lab work and INR levels. Mrs Abu’s pain management will continue after discharge, so education about the prescribed pain medication would be taught.
The nurse needs to provide these instructions in writing. Arrangements for follow up appointments with written details need to be given to Mrs Abu. A Discussion on nutritional needs and services such as a referral to a dietician, as well as a discharge summary for the GP.
Ensure Mrs Abu has all x-rays, scans, medical documents, medicines as well as all personal belongings. Also make sure Mrs Abu has transport home (Commonwealth of Australia 2009).
The nurse knows that for many patients, a hip fracture may be a threat (real or imagined) to their lifestyle. Depending on Mrs Abu and her level of support, the nurse may arrange a social worker to assess the need of services required after discharge. They will provide a list of community resources to meet the needs once Mrs Abu is discharged. Follow up are may be used by either visiting or phoning Mrs Abu to assess her transition to the home (Health Information Publications 2010).
Successful discharge planning for Mrs Abu will enable her to move from hospital to home with appropriate health professionals offering holistic care (Harris, Nagy, & Vardaxis 2006, p.541).
The nurse by assessing, planning, implementing and evaluating the discharge process, hopes to ensure quality of patient care by preparing and referring client and family to the relevant hospital and community care (Crisp & Taylor 2007, p.284).

Reference List
Ackley, B & Ladwig, G. 2008, Nursing Diagnosis Handbook, An evidence guide to Planning Care, 8th Edition, Mosby, Elsevier, USA.

Brown, D. & Edwards, H. 2008, Lewis’s Medical Surgical Nursing: assessment and management of clinical problems, Mosby Elsevier, Australia.

Commonwealth of Australia 2009, Department of Veterans Affairs, Discharge Planning, Canberra, Australia, http://www.dva.gov.au/service_providers/hospitals/Documents/dpclist.pdf, accessed 30 August 2010.

Crisp, J & Taylor, C. 2007, Potter & Perry's Fundamentals of Nursing, 2nd edn, Elsevier Mosby, Marrickville.

Galan Nicole, 2009, Choosing your subcutaneous injection site, About.com site, USA, http://pcos.about.com/od/medication1/qt/sqsites.htm accessed 2 September 2010.

Gulanick, Myers, Klopp, Galanes, Gandishar, Puzas, 2003, Nursing Care plans: Nursing Diagnosis and Intervention, Mosby, Elsevier USA.

Harris, P. Nagy, S. & Vardaxis, N. 2006, Mosby's Dictionary of Medicine, Nursing & Health Professions, Mosby Elsevier, Marrickville.

Health Information Publications 2010, How Do I Prepare For A Hip Replacement?, Nevada, USA,

http://www.ehealthmd.com/library/totalhipreplacement/THR_prepare.html accessed 23 August 2010.

MIMS Australia 2007, Mims Issue No 6 2007, St Leonard’s, NSW, Australia.

Tiziani, A. 2006, Harvard’s Nursing Guide to Drugs, 7th Edition, Elsevier Mosby, Marrickville, NSW.…...

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