Part a – You care for Sally after she has undergone surgery.
You identify acute pain as one of your nursing problems.
Sally will be as pain-free and comfortable as possible.
There are four (4) possible nursing interventions to reach this goal.
Part b. Explain why each nursing action or intervention is appropriate. Also, describe how you can help you reach your care goal today.
Two (2) indicators will show you if your care plan for Sally’s pain relief is effective.2:
Frank is treated with a diuretic in order to relieve his symptoms.
Frank’s urine output is low and you suspect he may be hypovolaemic.
On closer inspection, identify three (3) other clinical manifestations.
3: Frank Has A History Of Coronary Heart Disease
The bell rings to alert you.
You find him at his bedside looking concerned and telling you that it is not easy for him to feel well.
You are aware that it is possible he may be experiencing angina. The appropriate nursing action is for you to use the PQRST to assess his pain.4:
Frank is reporting increasing, more severe pain while you’re at his bedside. He also becomes extremely anxious, dyspnoeic and diaphoretic.
(a.) What conclusion would you draw from these symptoms?
(b). What are 2 of the most urgent nursing diagnoses/problems you currently have?
(c.) What are your initial 4 nursing actions or interventions?
D d. Determine 5 priority nursing assessments Frank should undergo after Frank becomes stable.
Frank will be stable once he has been treated, but he still faces complications.
Today, identify 2 potential complications for which you should be alert.5.
Robyn is suffering from a respiratory condition and you are supporting her.
to take a bath.
Robyn is breathless and pale. Her lips become duller and more dusky-pink.
Name 3 nursing priorities you will be implementing at this time.
Robyn should be able to return to bed after she is completely healed and has finished her daily hygiene.
What is the best place for Robyn’s nursing?6:
You are caring on a person who is just being admitted for major burns.
It’s 6 hours later.
Identify (a), The stage of burn management that the person is currently in
b. Five (5) high-priority, urgent nursing issues that will be documented on the nursing plan
c. Explain the connection between each of those nursing problems mentioned above and why it is important.
7: Max Was Admitted to Your Ward with Increasing
Abdominal pain, nausea or fullness. An abdominal xray taken at the emergency department showed a distended stomach and possibly fluid.
While his vital signs are slightly elevated since his admission, his pain score was 2 to 3, he still feels full and bloated.
The doctor has prescribed several broad-spectrum anti-biotics, including metronidazole. He also prescribed an antiemetic and prn medication.
(a). What conclusion would your body draw from these signs and symptoms.
b. Max’s abdomen, gastro-intestinal function and other issues are recognized.
Identify: A Five (5) Specific Assessments you will Perform as Part of Max’s Assessment b.
They will be explained as to why they are important and what you can expect from them.8:
Discuss when it is appropriate for nurses to conduct a focused assessment.
Answer to Question: NUR250 Medical Surgical Nursing 1
1 Acute Pain
It is important to assess the pain characteristics, which includes pain quality such as burning or sharp pain, where it occurs, how long it lasts, and the relieving and precipitating factors.
Reduce stressors and discomfort, if you can, as they can be aggravating factors in pain.
Give rest periods to promote sleep, relief, or relaxation.
The best pain relief method is chosen.
The pain assessment is the first step in pain management planning.
The patient is the best source of information about how severe the pain is.
Scales such the 0-10 scale, as well as visual analogues, are one way to determine different degrees of pain.
Different types of pain can be treated with different analgesics.
Nonopioid pain relief is for mild to moderate pain. Opioid pain relief is for severe pain.
Pain management is based on removing additional stressors.
Patients who are unable to deal with additional pain stimuli (interpersonal, external or psychological) may experience an increase or decrease in their pain.
Exercising could cause increased pain.
Pain is usually exaggerated when there is fatigue or discomfort.
Most people feel more relaxed in a peaceful and quiet environment.
If there are contraindications, patients with acute pain should be treated with a nonopioid medication.
Nonopioids act in the peripheral tissues and block the synthesis prostagradins which stimulate nociceptors.
The patient claims that she experiences less pain at a lower scale level, 3 or 4.
Sally will be able to demonstrate and show improvement on parameters such a improved pulse rate and blood pressure as well as a relaxed or comfortable body posture.
Frank also has 2 additional clinical manifestations that can be assessed
Hydration can lead to loss of skin elasticity.
The skin is cold and clammy, but it’s pale
Dry mucous membranes and anxiety3.
Items Tested with the PQRST Penneumonic
P-Provokes: What causes the pain, makes things better or worsens it?
Q-Quality- What is the sensation of pain? Is it sharp, dull, stabbing or burning?
The patient should be able to describe the pain with no pressure, so that he/she can provide the correct information.
R-Radiates is the pain in one area, does it radiate?
S-Severity: What is the severity/degree of pain on a scale between 0-10?
T-Time: When did the pain first start? How long has it been?4.
Conclusion from signs and symptom
Frank is currently in hypovolemic shocked and requires immediate interventionTwo highest priority nursing diagnosis
Acute pain is a sign of the disease process. Patients report a worsening in their pain.
Poor breathing patterns are a sign of the disease process. This can be seen in patients becoming more anxious and dyspnoeic.Four immediate nursing interventions
Do not take opioid painkillers.
You can administer opioids orally. However, it is best to use intravenous infusions because they are fast.
Opioids should be prescribed for severe pain.
You should administer oxygen by using a nasal prongs and oxygen mask at approximately six liters/hour.
If you notice difficulty in breathing, it is important to immediately seek medical attention.
Assist the patient by placing him in the supine place.
Supine position promotes comfort and better breathing.
For patients on oxygen, the best position for them is supine.
Make sure to remove all clothing and ventilation.
This is to prevent excessive sweating.
Relax the patient and assure them that they will be able to manage their anxiety.
Five priority nursing assessments
Monitoring oxygen saturation levels and oxygen respiratory rate should be performed.
The respiratory rate should range from 10 to 28 breaths/minute, and oxygen saturation shouldn’t be less than 90.
Keep track of vital signs every two hours.
Vital signs include blood pressure, heart beat, pulse, and respiration rate.
Vital signs provide basic information about an individual’s well-being.
Any deviation from the usual will indicate if there is progress in management towards positive outcomes, or towards negative outcomes.
Evaluate the fluid balance and level of dehydration.
This is done to help determine how much fluids should be given to the patient per hour.
Assess the level of anxiety.
Anxiety that is increasing will make the condition worse.
Nurses must assess if the anxiety levels have decreased or increased.
It is important to assess your level of comfort.
Nurses need to assess the level of comfort for each patient and adjust their position accordingly.
Comfort helps ease anxiety and promotes healing.
It is crucial to turn the patient over after each two hours.
Two possible complications
Kidney damageBrain damageHeart attack 5.
Priority nursing actions
Examine the level of anxiety.
Anxiety could cause the client to be unable to breathe properly.
Albuterol is a short acting beta2 agonist.
Cold showers can make it more difficult to breathe and cause patients to collapsing.
Short-acting beta-2 agonists are bronchodilators. They relax the muscles that line the airways carrying air to their lungs.
Pay attention to breath sounds as well as any other stimuli such like wheezes or stridor.
Bronchospasm can cause wheezing.
The signs of respiratory problems include wheezing that is decreasing.
Other sounds may be due to complications, such as pneumonia
The most suitable place and why
The best position for patients is the high fowler’s tripod, in which they sit forward with their hands on their knees.
This position is ideal for oxygenation as it allows maximum chest extension. 6.
Phase of the burning
Management of emergency burns – The management of an emergency burns is done within the first 48 hours, when the highest nursing priority are considered.
Five Priority Issues in NursingImpaired gaseous exchange
Acute painFluid volume deficit
What does the preceding priority mean and why is it important?
The causes of impaired gaseous interchange are smoke inhalation poisoning, obstruction of the upper lungs and carbon monoxide poisoning.
Edema and the additional effects of smoking inhalation could also be related.
This is a major nursing priority in emergent fire management. It promotes gas exchange and clears the airways.
Critical nursing interventions include the provision of humidified air, pulse oximetry monitoring, assessment and evaluation of respir rate and breath sounds.
Fluid volume deficit is caused by factors such evaporation loss from wounds, and injuries of blood vessels which increase the capillarypermeability.
This is a key nursing priority because it allows you to restore fluid or electrolyte loss from the burns.
Monitoring electrolytes levels, fluids infusions regularly, and monitoring input and outflow are all major nursing interventions.
Hypothermia occurs when there are open wounds present and the microcirculation around your skin is reduced.
This is essential to maintain the body’s temperature.
The lower body temperature causes body enzymes to be inactivated, which can lead to poor metabolic activities.
Acute pain can result from nerve and tissue damage caused by the burn.
This is to alleviate pain and encourage comfort.
Anxiety stems from factors such as fear, psychological effects and anxiety due to the burn injury.
The goal is to reduce anxiety in the patient and family members and increase comfort. 7.
The patient is suffering small bowel obstruction.
Obstructive intestinal syndrome can lead to symptoms like an intestinal loop that may be causing obstruction, abdominal fullness and fluid levels.
Five assessment options, why you should do them and what they can tell you
Inspection- This is the visual inspection of the entire abdomen.
The patient should be supine.
Inspection is used to detect distention, abnormal breathing patterns and colorations.
The presence of small bowel obstruction may cause an increase or decrease in abdominal girth.
Auscultation- This is done prior to percussion and palpation. It prevents bowel sounds from being altered.
The stethoscope listens to all four quadrants in the abdomen for bowel sounds.
If there is bowel obstruction, you may hear tickling sounds. These sounds can be normal or hyperactive.
Percussion- This is a technique that uses percussion to indicate sounds that can help identify the root problem.
When percussion is used to detect intestinal obstruction, there will be a resonance sound which can indicate the presence or absence of fluids or gases.
For pain control, it is important to observe the patient’s movements and conditions during percussion.
Palpation- With palpation, one can assess the skin for tenderness and moisture.
When the skin is dry without moisture, there may be palpable masses that indicate obstruction. Tenderness can also be felt at the extended site.
Look out for signs of dehydration like poor peripheral perfusion or hypotension.
It is caused by water not being absorbed into the bowel or vomiting.
The patient cannot also replace the water that has been lost orally.
Pyrexia may be a sign of perforation.
Why would max need a Nasogastric tube?
For the purposes of aspiration prevention and initial decompression of the intestinal contents, patients with intestinal obstruction may have a nasogastric device inserted.
A nasogastric tub is continued to reduce intraoperative compressions. The tube also provides symptomatic relief, thus benefiting patients.
How to check that the tube has been placed in the right place
To ensure that the tube is securely in place, attach a needle to the end.
After attaching, ensure that no air is inserted.
Aspirate some of the gastric contents.
The pH of the aspirated contents should be tested to make sure it is not acidic.
Use litmus paper to check the pH. It should be lower than pH 6.
Before you proceed with aspirating, get an x-ray.
This is the aspirate to get from a nasogastric tub and why
This is the aspirate you can expect from the tube.
Most gastric color visualizations and colors should look cloudy, bloody, blown, and/or green.
The presence of bile causes yellowish pigmentation in the intestines.
Respiratory aspirate most often contains blood, so the above can be called gastric aspirate.
It is important to monitor parameters when the drainage of the nasogastrictube occurs.
If it fails to drain or aspirate, the patient should be placed to the left. This will allow the gastric contents of the stomach to reach the greater curvature. After that, the aspiration should be done again.
If no drainage can be seen, the tube must be extended up to five centimeters. After that, inject 10cc air into the tube and make sure the stethoscope makes air sounds.
An X-ray should also be taken to verify that the tube is correctly placed.
Orders for medical treatment
Hydration & nutrition
From the moment that the obstruction has been removed or treated, there is a null oral charge.
Infusion of intravenous fluids including normal saline and 5% glucose for nutrition purposes
Administration of intravenous nutritional vitamins and minerals
The nasogastrictube is the best way to get rid of gastric content.
After a time period, the nurse should aspirate gastric material.
Monitor and record fluid output and input.
8. Focus Assessments: When is it appropriate?
Focus assessments often involve data collection to identify the problem.
This type is typically less comprehensive and takes less time that the initial assessment.
This assessment is used to determine if the problem is still present and if the situation has changed.
This includes checking for any improvements, resolving the issues and determining if the problem is worsening.
The assessment can also check for new concerns and misdiagnosis.
Focus assessment is performed occasionally by some medical areas such as intensive care units.
Focus assessment can be used to assess the health of one or more systems.