Nursing Assessment and Care

1a. The Neurological assessment in case of brain injury can be conducted by the use of the Glasgow coma scale. The components are motor, verbal and eye responses and these responses are scored from one to six, one to five and one to four respectively (Reith et al., 2016). Glasgow coma scale is formed by the sum of the scores of all the three components and during the subsequent assessment, if the Glasgow coma scale score reduces the nurse can recognize a compromise in the neurovascular status of the patient (Jain et al., 2019).

1b. For the maintenance of hygiene of the patient the guidelines that are the nurses are expected to follow. They are- the personal hygiene of the patient is to be done as per the requirement as well as the preference of the patient, the patient is to be given complete privacy when the personal hygiene is being carried out, oral hygiene should be considered as a part of personal hygiene, the patient should be encouraged to maintain hand hygiene, the healthcare personal should maintain hand hygiene before and after giving personal hygiene and the healthcare personnel should wear gloves and masks while performing the personal hygiene (Hørdam et al., 2017). While assisting Dan it is required that his needs and preferences are assessed first, it has to be made sure that no one else is present other than nurse and him in the wards. Before starting the nurse should perform hand hygiene followed by the use of gloves and masks to protect the patient. Dan is encouraged to maintain hand and oral hygiene and nurse is to perform hand hygiene after personal hygiene is completed.

1c. From the chart the medication that is recommended for Dan is paracetamol. Though the number on the pain scale as given by Dan is 7 which are between moderate and severe and ideally oxycodone could be administered but as the patient has undergone brain injury it is not advisable. Paracetamol is a non-steroidal anti-inflammatory condition which cannot cause dependence and can be administered with the least adverse effects (Suciu et al., 2019).

1d. One tablet of 1000mg needs to be administered to the patient.

1e. The physician should prescribe the drug under its generic name and this is because the recent guidelines for the prescription require a physician to do so and it is better than trade name as different medication with the same basic drug can be given (Choudhry et al., 2016). The classification that is used should be prescription only medication and it is done so that medication error can be avoided (Korb-Savoldelli et al., 2018).

1f. Dan can be discharged home after the cast has been placed for stabilization of the fracture has been done after open reduction and internal fixation. The neurological assessment of Dan should be such that he has the best score of 15. Reduction of pain is another aim that needs to be achieved before he can be discharged and once the pain score is below 3 it can be contemplated that he is discharged which can take two weeks.

1g. The patient might require assistance with the completion of activities of daily living as his partner is pregnant and might not be able to help him. The other referral that Dan needs to be given is for physiotherapist so that once his fixation is completed he can rehabilitate the complete function of the limbs (Münter et al., 2018).

2a. The patient’s characteristics that are provided in the case and are related to the increased risk of fall in case of Ms Evans are: she is elderly, she has a visual impairment and requires glasses, she lives alone, she uses a walking frame, and she has a history of tinnitus and is diagnosed with vertigo.

2b. First, signs should be provided so that Ms. Evans can be identified and risk prevention measures can be taken by everyone on the care team (Callis, 2016). Second, the patient can be transferred to a room closer to nurses’ station which can help constant observation. Third, things required by the patient can be kept within reach of the patient as it will cause fewer hazards and fall can be prevented. Fourth, the position of bed should be lowest so that risk of falling can be reduced (Callis, 2016).

2c. The level of consciousness can be assessed by the use of various tools. One of the tools that are used for the assessment which is very simple and that is AVPU assessment. If the patient is completely aware and alert with respect to the time, place and person and is talking the patient is marked A that is the patient is awake (Romanelli & Farrell, 2020). If the patient is not fully awake but responds when spoken to and verbal stimulation the patient is marked as V (Romanelli & Farrell, 2020). If the patient does not respond to voice or touch a painful stimulus like a pinprick or pinch can be used to elicit a response and the patient is marked as P (Romanelli & Farrell, 2020). If the patient is not responsive at all the patient is marked U for being unresponsive (Romanelli & Farrell, 2020). The other tool that is most commonly used and is more objective is the Glasgow coma scale score. It can be used bedside and have three behavioural components that are assessed and they are verbal, eye and motor response. Eye response is categorized as spontaneous=4, to sound=3, to pressure=2 and none=1; verbal response is categorized as oriented=5, confused=4, words=3, sounds=2 and none=1; motor response is categorized as obeys command=6, localize pain=5, normal flexion=4, abnormal flexion=3, extension=2, and none=1 (Nik et al., 2018). Depending on the response that is elicited from the patient a score is given and 15 is the best response, the comatose patient is less than 8 and unresponsive is 3.

2d. GCS score for eye response- 3, verbal response- 4 and motor response- 6. The total is 13.

2e. Identification- Ms Evans a seventy-year-old woman currently in ward 1B who was admitted to the ward via ED. Situation- there is the development of weakness of the upper limb, the patient had higher blood pressure and the pain score was an eight on a ten-point scale. She was administered with her regular medication for hypertension and she was feeling nauseous and had vomited after breakfast in the morning. Background- Ms Evans was brought to the emergency after suffering from a fall. Though she has slight visual impairment which requires glasses and she lives alone and has suffered a laceration on her right anterior tibia and her GCS on admission was 15. She has a history of chronic heart failure, hypertension, tinnitus, glaucoma, anxiety, depression, urinary tract infection and rheumatoid arthritis. Her current medications included Atenolol, Aspirin, Frusemide and Alprazolam. She has a known allergy to shellfish. She has been admitted to the hospital for the investigation of unexplained weight loss, urinary infection and vertigo. Assessment and action- the current assessment showed that the GCS score has reduced to 13 and she is showing signs of confusion and decreased eye response. There are signs of weakness in her upper arm with increased blood pressure and pain rest of the vitals remains normal. She was feeling nauseated and vomited soon after breakfast. Response- as the condition of the patient is deteriorating it is required that the patient is reviewed by a physician within the next thirty minutes.

2f. When a nurse is taking verbal orders from the physician or specialist doctor it is required that few things are to be considered while taking these orders. As a registered nurse on the receiving on the end of the verbal order should identify the patient properly in terms of name, age and appropriate weight (Jose, 2016). The generic name of the drug is to be taken and the dosage form like tablets, capsules, inhalants or topical preparation. The most important thing is to take the exact dosage, concentration, dose, frequency and route of administration. Name and designation of the prescriber along with the telephone number if required and read-back technique are to be employed (Jose, 2016).

2g. the format is filled by the client and it looks appropriate

2h. The dose ordered in 25mg and strength available is 50mg so the tablet can be calculated as 25/50 that is a half tablet.

2i. A valid medication order must be such that they adhere to quality indicators in terms of preparation as well as the administration of the medication (Smeulers et al., 2015). To make sure that safe medication is administered to the patient it is required that the healthcare professionals practice the seven rights of medication administration. The rights that are to be followed are right drug, right patient, right dose, right time, right route, right reason and right documentation (Smeulers et al., 2015).

3a. COLDSPAA has following components which can help in the ascertainment of the pain. The expansion describes the components that are required for the assessment by the healthcare professionals including nurses (Claassens, 2017). It includes character, onset, location, duration, severity, pattern and associated factors. Mrs Edwards would be asked how she feels the pain is in terms of strength and intensity. Next, the patient would be asked when the pain began that is onset, in this case, it is more likely it began when she had a fall and got her hand fractured (Claassens, 2017). Next Mrs Edwards is asked where she feels the pain is the most and does she feel pain anywhere else this is to know the location of and radiating nature of the pain. The duration of the pain is assessed next that is the patient is asked for how long there is pain and does it recur. The severity of the pain is next the patient is asked how bad is the pain and the extent to which it bothers her (Claassens, 2017). Next, the patient is asked what makes it better or worse. Lastly, the patient is asked for an assessment that any other symptoms occur with the occurrence of pain and what effect does it have on her (Claassens, 2017).

3b. The pain which is experienced by Mrs Edwards can be considered as mild pain and she can be given paracetamol for the management of pain. Paracetamol is administered in case of mild to moderate pain. It is a non-steroidal anti-inflammatory drug with the least probability of dependency (Suciu et al., 2019).

3c. For the administration of medication in patients, there are rights are to be maintained and they are right patient, medication, dosage, route, time, documentation, client education, right to refuse, assessment and evaluation (Alemu et al., 2017). In case of Mrs Edwards, it has to be made sure from the medication administration records the correct patient’s name is mentioned and right medication is given as per the condition of the patient in the right dosage. There is a minimum time after which a medication can be administered which needs to be followed. All the medications after administration should be documented properly. Mrs Edwards need to be educated regarding any adverse effect that medications might have. After medication, it is required that the effects are assessed and evaluated by the assessment of pain. In the case of Mrs Edwards as well it has to be made sure that all the components are followed properly so that adequate management can be done.

3d. The nursing intervention for the increased pain in the present case would be to manage the pain by modifying the medication given for the management of pain. The appropriate medication would be to administer opioid pain medication after reporting the changes to the doctor and obtaining prescribed orders from the doctor.

3e. From the medication administration record that has been formed for Mrs Edwards, it is seen that the first medication that is to be administered is Hydralazine 50mg orally which is given for hypertension. The second medication that is to be administered to Mrs Edwards is Indapamide hemihydrate 2.5mg orally and this is a medication which is administered daily. The medication administration record identifies the patient as well as the prescriber properly.

3f. In the administration of the medication assessment is a step that is done prior to the administration. Assessment includes an assessment of pain, cardiac and respiratory. It is required so that the pain can be assessed and modification of medication can be done. Cardiac and respiratory assessment is required to be known as few medications can depress cardiac as well as respiratory systems (Schiweck et al., 2019).

3g. For Hydralazine the dosage required is 50mg and the stock strength available is 25mg so the tablets required are two. For Indapamide hemihydrate the medication required is 2.5mg and the dose available in the same and tablet required is one.

3h. The nursing assessment that is required for the patient is to check for the pattern, frequency and consistency of stool. The medication including the usage of laxative and enema use, type of frequency needs to be taken into account (Blekken et al., 2016). The dietary habit including that of liquid intake should be assessed along with the lifestyle as a prolonged sedentary lifestyle can cause changes in bowel movement. Other factors like fear of pain, the requirement of privacy and underlying neurogenic disease need to be evaluated. Nursing interventions that can be done in the present case is to encourage the patient to take more fluid, and increase dietary content in the food, some regular exercise like simple walking can be done (Blekken et al., 2016). If there is obstruction due to impaction of fecal material might require digital elimination. In a hospital setting, the patient should be encouraged to eliminate as much as possible and give adequate privacy.

3i. In the case of Mrs Edwards as she is an aged patient is can affect the bowel movement. This is because the movement of food in the bowel becomes slow with age and it affects absorption as well and it results in more water is absorbed from the gut which can cause constipation.

3j. Due to pain, the patient is not able to walk and it is one nursing diagnosis for constipation.

4a. Standard precautions those are required in special circumstances include hand hygiene, wearing of appropriate personal protection equipment, handling of patient equipment, injection safety practices, cleaning of the environment, respiratory hygiene, laundry handling, and room placement of patient (Gebremariyam, 2019). The situation where this might be required is if the patient has a contagious infection which can spread rapidly. If the patient has generalized body burns as in that case the patient might have increased chances of getting infected due to environment. If the patient has a condition congenital or otherwise when the immunity of the patient is reduced it is required that standard precautions with PPE are to be used. If the patient has large open wounds it would be required that the patient is kept away from infections as it may deem fatal (Gebremariyam, 2019). The PPE in the case of Mr Graham is aprons, gowns, gloves, masks and the cover for shoes all of which are required to be disposable (Kampmeier et al., 2018).

4b. The apical pulse is located on the left side of the chest at the site of 5th intercostal space at the midclavicular line. For the location of the apical pulse, it is required that the patient is lying on his back. After this, the sternal notch is to be located it is located between the clavicles and it's notched above the sternum (Douglas et al., 2016). The index finger is taken slightly down along the same line till a hump it felt and this angle is called the angle of Louis. The finger is slid over the second intercostal space this is repeated till 5th intercostal space here apical pulse is palpated as well as auscultated (Douglas et al., 2016). For auscultation, first, it has to be made sure that the stethoscope is clean as the diaphragm is used. The apical pulse and beats are counted for a full one minute this is adult patients it should be greater than 60 beats per minute or more. If the apical pulse is difficult to auscultate the patient can be asked to lean towards left as the heart will move closer to the chest wall and it will be easier to auscultate. Apical pulse must be auscultated in case of the irregular pulse because it is required to know if each beat is getting transmitted (Douglas et al., 2016).

4c. North American Nursing Diagnosis Association is a nursing assessment process which is required for the nursing diagnosis. From the assessment notes that have been collected as per notes, it can be diagnosed that the patient is suffering from deterioration of the cardiac condition.

4d. Oxycodone is a medication that is provided to the patient for the reduction of pain but in the current case where there is already cardiac depression, this should be avoided as it can further cause cardiac depression (Alpert et al., 2017). The other medication that can be given instead of this patient should be a non-steroidal anti-inflammatory drug.

5a. Five moments for hand hygiene is given by the World Health Organization all of which the healthcare professionals are required to follow to maintain patient safety and reduce the incidence of hospital-acquired infection (Sax et al., 2017). First, hand hygiene should be maintained before touching a patient and it is done to reduce the transmission from inanimate surface to the patient. Second, it should be done before any aseptic procedure and it is done to make sure that asepsis is maintained. Third, if there is any risk of exposure to body fluid hand hygiene should be maintained and it is done because it increases the chances of transmission of infection present in the patient to the healthcare professional (Sax et al., 2017). Fourth, hand hygiene should be managed after touching a patient so that the infection present in one patient is not transmitted to others. Lastly, after touching the surroundings of the patient so that cross-infection can be reduced (Sax et al., 2017).

5b. (The documentation needs to be done by the client) as per the track and trigger sign, it can be seen that the patient falls in the category of review and rapid action for which the doctor is informed about the condition of the patient as it is deteriorating rapidly and intervention is required.

5c. advantages:

  • Temperature can be taken from a distance
  • It can measure the temperature of the surface
  • It can be used in various conditions
  • It has memory can be used to compare with previous readings
  • They are compact
  • They are easy to use

Disadvantages:

  • Presence of layer can impair reading
  • Presence of dust can also impair reading
  • The accuracy can be marginal
  • They are expensive
  • Humidity can affect the temperature of the patient
  • Sensors might be affected which can affect the reading

5d. the nursing assessment for the respiratory condition can be done by inspection and observation. The patient’s respiratory rate is the first element which needs to be assessed as the normal respiratory rate is between 12-20 breaths per minute (Lewis et al., 2016). In the present case, it is seen to be more which means the lungs are working more to fulfil the requirements of the body. The patient should be assessed for the signs of use of accessory muscles of respiration and it is done to assess the effects of respiration. Oxygen saturation of the patient needs to be assessed which can be done by the use of pulse oximeter so that the effect of respiration can be assessed on the oxygen saturation of the patient (Lewis et al., 2016). Arterial blood gas analysis needs to be done as more the oxygen saturation is reduced it increases the chance of respiratory acidosis.

5e. As per calculation, 27.7mL of amoxicillin is to be administered.

References for Nursing Assessment and Care

Alemu, W., Belachew, T., & Yimam, I. (2017). Medication administration errors and contributing factors: A cross sectional study in two public hospitals in Southern Ethiopia. International Journal of Africa Nursing Sciences7, 68-74. https://doi.org/10.1016/j.ijans.2017.09.001.

Alpert, C. M., Smith, M. A., Hummel, S. L., & Hummel, E. K. (2017). Symptom burden in heart failure: Assessment, impact on outcomes, and management. Heart Failure Reviews22(1), 25-39. https://doi.org/10.1007/s10741-016-9581-4.

Blekken, L. E., Nakrem, S., Vinsnes, A. G., Norton, C., Mørkved, S., Salvesen, Ø., & Gjeilo, K. H. (2016). Constipation and laxative use among nursing home patients: Pevalence and associations derived from the residents assessment instrument for long-term care facilities (interRAI LTCF). Gastroenterology Research and Practice2016. https://doi.org/10.1155/2016/1215746.

Callis, N. (2016). Falls prevention: Identification of predictive fall risk factors. Applied Nursing Research29, 53-58. https://doi.org/10.1016/j.apnr.2015.05.007.

Choudhry, N. K., Denberg, T. D., & Qaseem, A. (2016). Improving adherence to therapy and clinical outcomes while containing costs: Opportunities from the greater use of generic medications: Best practice advice from the Clinical Guidelines Committee of the American College of Physicians. Annals Of Internal Medicine164(1), 41-49. https://doi.org/10.7326/M14-2427.

Claassens, T. (2017). Nursing a patient with acute pain. Kai Tiaki: Nursing New Zealand23(7), 15.

Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S., & Gardner, G. (2016). Nursing physical assessment for patient safety in general wards: Reaching consensus on core skills. Journal of Clinical Nursing25(13-14), 1890-1900. https://doi.org/10.1111/jocn.13201.

Gebremariyam, B. S. (2019). Determinants of occupational exposure to blood and body fluids, healthcare workers’ risk perceptions and standard precautionary practices: A hospital-based study in Addis Ababa, Ethiopia. Ethiopian Journal of Health Development33(1).

Hørdam, B., Brandsen, R. V., Frandsen, T. K., Bing, A., Stuhaug, H. N., & Petersen, K. (2017). Nurse-assisted personal hygiene to older adults 65+ in home care setting. J of Nursing Education and Practice, 8(2), 23-28. https://doi.org/10.5430/jnep.v8n2p23.

Jain, S., Teasdale, G. M., & Iverson, L. M. (2019). Glasgow Coma Scale. In StatPearls [Internet]. StatPearls Publishing.

Jose, N. (2016). Medication errors: Don’t let them happen to you. Indian Journal of Surgical Nursing5(1), 17. http://dx.doi.org/10.21088/ijsn.2277.467X.5116.1.

Kampmeier, S., Kossow, A., Clausen, L. M., Knaack, D., Ertmer, C., Gottschalk, A., ... & Mellmann, A. (2018). Hospital acquired vancomycin resistant enterococci in surgical intensive care patients–a prospective longitudinal study. Antimicrobial Resistance & Infection Control7(1), 103. https://doi.org/10.1186/s13756-018-0394-1.

Korb-Savoldelli, V., Boussadi, A., Durieux, P., & Sabatier, B. (2018). Prevalence of computerized physician order entry systems–related medication prescription errors: A systematic review. International Journal of Medical Informatics111, 112-122. https://doi.org/10.1016/j.ijmedinf.2017.12.022.

Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences.

Münter, K. H., Clemmesen, C. G., Foss, N. B., Palm, H., & Kristensen, M. T. (2018). Fatigue and pain limit independent mobility and physiotherapy after hip fracture surgery. Disability and Rehabilitation40(15), 1808-1816. https://doi.org/10.1080/09638288.2017.1314556.

Nik, A., Andalibi, M. S. S., Ehsaei, M. R., Zarifian, A., Karimiani, E. G., & Bahadoorkhan, G. (2018). The efficacy of glasgow coma scale (GCS) score and acute physiology and chronic health evaluation (APACHE) II for predicting hospital mortality of ICU patients with acute traumatic brain injury. Bulletin of Emergency & Trauma6(2), 141. https://doi.org/10.29252/beat-060208.

Reith, F. C., Van den Brande, R., Synnot, A., Gruen, R., & Maas, A. I. (2016). The reliability of the Glasgow Coma Scale: A systematic review. Intensive Care Medicine42(1), 3-15. https://doi.org/10.1007/s00134-015-4124-3.

Romanelli, D., & Farrell, M. W. (2020). AVPU (Alert, Voice, Pain, Unresponsive). In StatPearls [Internet]. StatPearls Publishing.

Sax, H., Allegranzi, B., Pittet, D., & Boyce, J. M. (2017). My five moments for hand hygiene. Hand Hygiene: A Handbook for Medical Professionals, 134-143.

Schiweck, C., Piette, D., Berckmans, D., Claes, S., & Vrieze, E. (2019). Heart rate and high frequency heart rate variability during stress as biomarker for clinical depression. A systematic review. Psychological Medicine49(2), 200-211. https://doi.org/10.1017/S0033291718001988.

Smeulers, M., Verweij, L., Maaskant, J. M., de Boer, M., Krediet, C. P., van Dijkum, E. J. N., & Vermeulen, H. (2015). Quality indicators for safe medication preparation and administration: A systematic review. PloS ONE10(4), e0122695. https://doi.org/10.1371/journal.pone.0122695.

Suciu, M., Suciu, L. I. A. N. A., Vlaia, L., Voicu, M., Buda, V. A. L. E. N. T. I. N. A., DRĂGAN, L., ... & Cristescu, C. (2019). Prevalence and the patterns of use of non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol among the general population. FARMACIA67(2), 337-345. https://doi.org/10.31925/farmacia.2019.2.20.

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