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Nursing Assessment and Care

Table of Contents

Introduction.

Assessment of Patient.

Nursing Diagnosis.

Plan and target the patient.

Nursing Implementation.

Evaluation.

Conclusion.

References

Introduction to Professional Experience Practice Analysis

The nursing procedure is an efficient way to provide integrated nursing care where there are five main phases, such as evaluation, diagnosis, planning, implementation and assessment. It provides a systematic way to solve problems for nurses to apply their knowledge into practice, which can be beneficial to both the patient and the nurse. This study will use the framework of nursing process to talk about the role of registered nurse in handling the health difficulties of patients admitted in the hospital with several health matters, especially talking about their care once shifted to the renal department from urology as well as how effective specific nursing involvements are in managing the health issues (Beldon, 2013).

Introduction to the Patient

Ms. Mei Li, a 79-year-old lady was taken by ambulance to the emergency room of the Melbourne Metropolitan Hospital before two weeks. Besides, she reported with raising difficulty and painful urination, showing a deficiency of interest in drinking and eating alongside major swelling of the legs under the knees. Additionally, she stated that her signs started about one week before the presentation. She was admitted in the urology section, which diagnosed her with awkward uropathy subordinate to the “acute on chronic kidney injury” (AOCKI), fluid overload as well as swellings to the legs.

She has the history of “hypertension (HTN), hiatus hernia (associated gastroesophageal reflux disease [GORD]), metastatic breast cancer (right mastectomy and lymphadenectomy 2007), vitamin D deficiency, gout, obstructive uropathy (bilateral stent insertion December 2018) obesity, thyroidectomy, end stage kidney disease (ESKD), type II diabetes mellitus (T2DM), and nonalcoholic steatohepatitis (NASH)”. Further, she has also a family history of HNN, ischemic heart disease, obesity, and T2DM. She reported nil allergies.

She lives alone and did not receive any home facilities or any support for her health. Besides, her relative is her brother, who lived very close to his wife and child, who often met him at her residence.

In the urology department, she experienced an effective exchange of the bilateral uretic stents the day after admission to the treatment of obstructive uropathy, the disorder that arises when there is scarce drainage of urine in relation to the urine production of the kidney. She was moved to the renal department 5 days after admission.

Assessment of Patient

  1. General Assessment

Her condition was measured using a head-to-toe assessment, which was done upon entering the renal ward after consent was collected. Moreover, the patient can be seen relaxed in her bed with her legs a little raised and can easily communicate with the nursing staff. The patient looked to be washed and able to take care of herself as well as can ambulate using a four-wheeled frame that remains at the side of her bed within reach at all times (Boltz, 2016).

  1. Cardiovascular system (CVS)

The heart rate of the patient was 70 beats for each minute as well as the apical and radial pulses were palpated, both representing a strong and regular heart rate. Additionally, blood pressure was estimated at 180/97 that was higher than normal for the patient, and on auscultation, both hearth sounds (S1 and S2) were presented with no uneven sound heard. Further, the extremities of patient were well-perfused and pink, including a capillary refill time of 2 seconds. Also, severe peripheral pitting oedema occurs in the lower part of the legs with major serous fluid leakage noticed in both organs. She has the right “atrioventricular fistula” (AVF) exist, all of which should be observed in the left arm (Byers & Rochon, 2018).

  1. Central nervous system (CNS)

The neurological evaluation was assumed on admission with the patient with a score of 15 out of probable 15 on the “Glasgow Coma Scale”. The patient was aware and concerned with person, place, and time. Students are fair and responsive. She showed normal strength as well as movement in the upper limb, including slight weakness in the lower limb can affect her capability of moving them. Furthermore, she also reported no changed or decreased sensation in her limb (Georgiades, 2016).

  1. Respiratory system

She showed with no enlarged work of breathing, specified by no practice of attached muscles throughout exhalation or inhalation as well as deprived of any shortness of breath. Also, patient showed the respiratory rate of 19 breaths for each minute that was between normal limits and could keep an oxygen saturation (SpO2) of ≥ 95% on room air (97% when firstly evaluated upon the ward). There was no abnormal breath sounds on hearing the palpation and auscultation, both lungs were increasing in symmetry, including no tenderness or masses noticed (Gillespie et al. 2014).

  1. Gastrointestinal system(GIT)

Before admitting in the ward, and throughout the stay, she can follow a good renal diet. Besides, the renal diet is low in potassium, phosphorus, and sodium to help in maintaining kidney function and prevent complications associated with kidney failure. She reported zero pain in the GIT portion. While she reported nausea and was seen carrying the emesis bag on more than once, but she did not make vomit. After palpation, abdomen is soft, including no palpable tenderness or masses as well as normal bound sound can be heard on auscultation. She can open her bowel by documenting a reasonable amount of stool, which was Type 3 upon the “Bristol Stool Scale” (Jeyapala et al. 2015).

  1. Musculoskeletal System

The falls risk evaluation was performed in relation to the admission of patient to the ward. Further, she was thought to be at risk of high falls because of her age, current history of fall, limb weakening and polypharmacy. The patient can ambulate on the way to the bathroom under supervision using a four-wheeled frame (Haesler, 2018).

  1. Renal system

She was positioned on the fluid limit of 1.5 liters for every day and maintained the firm fluid balance chart. She urinates in a pan, voiding about 40 ml of urine each hour. Also, urine is standard in opacity and color. She deprived of pain on palpation of the kidneys or at the time of voiding (McGloin, 2015).

  1. Psychological well-being

She seemed flat on event, mainly when her family are not able to visit. But the patient was familiar with the nurse and desired to take part in the discussion at all times. She expressed the emotional state of being a weight on her family, therefore, social work referral was reported to make a discharge plan for her (Miller, Jerosch-Herold, & Shepstone, 2017).

  1. Integumentary system

Along with pituitary edema of the legs, she was showed in a ward with two skin tears to the right leg that were dressed with the use of jelonet, crepe, and combine. Additionally, the patients had severe haematoma on her left leg foot that was deroofed and then dressed through the similar method as her right leg. Moreover, pressure injury evaluation was assumed, there were no signs of stress trauma. However, according to the Braden scale, she was evaluated the risk of high-pressure injury (Morris et al. 2018).

  1. Metabolic system

She is a kind of both diabetic and casual regular “blood sugar level” (BSL) was reported. Besides, her BSL is usually in the range of 5-8 mmol/l that is among the expected range. She did not report any symptoms associated with her T2DM. But her leg injuries are a cause for concern as there is a possibility of gradual healing in relation to “diabetes-induced peripheral vascular impairment” (Pickering & Marsden, 2015).

  1. Medication

She has prescribed the regular medication list because of the patient having a long-term list of comorbidities. Important for her nursing diagnosis is high dose of Furosemide, diuretic, recommend by the health care in an effort to help in offloading some 10L of fluid overload, which is producing the peripheral oedema of patient (Taskın Yilmaz, Sabanciogullari & Aldemir, (2015).

Nursing Diagnosis

Diagnosis of actual nursing

Chronic failure of renal is associated with Excess fluid volume and this is indicted by important peripheral oedema of the lower extremities.

Possibility of nursing diagnosis

Risk of skin integrity which is related to the loss of mobility as well as peripheral oedema.

Plan and Target the Patient

Plan and goal for actual nursing diagnosis

Among 2 weeks, she returns to the proper fluid and electrolyte balance, as evidenced by the normal range, especially blood pressure, weight loss of at least 8 kg, and severe symptoms measured in peripheral oedema solution.

Potential Nursing Diagnosis Plans and Goals

The patient's skin remains intact, there is no trauma during stay (there is a risk of about 2 weeks) as well as the present skin tears heal slowly before discharge. Additionally, it is evidenced by the absence of pressure ulcers or ulcers, along with the deficiency of new tears on the skin, especially the lower legs of the oedematous.

Nursing Implementation

Intervention in actual nursing diagnosis

  1. In an attempt to develop the peripheral oedema of the patient, her legs should be extended as soon as possible. The roles of the nurse are not only to teach the importance of the patient, but also to actively improve the patient's legs properly and actively move the patient to a comfortable place where he can extend her legs. Lumbar elevation is a technique applied to relieve edema by more effectively promoting lymphatic and capillary function and venous lavage. Leg height is recommended as the finest practice material when treating lymphadenoma and preventing complications for example leg ulcers. Although there is no usual guiding principle, it is prescribed to bend the knees slightly to avoid excessive tendencies, to support the lower limbs and to improve the legs above the hips (Younas, 2017).
  2. The “Fluid Balance Chart” (FBC) is a vital instrument to determine a patient's hydration status and also ensures that the patient has not exceeded their fluid limit. Besides, the fluid balance chart records a patient’s fluid intake and output over a 24-hour period. In this circumstance, the patient's fluid limit is 1.5L. In this way, it means the net intake of body fluid should be less than 1.5L. The role of the nurse can be used by multidimensional teams to guide a patient's clinical decision and to document it properly through the appropriate use of FBC. If FBC is not used properly misinformation can be properly accounted for and can be dangerous. To use FBC properly, the nurse's documentation must include all receptions and outputs in accordance with hospital protocols. These include accurate measurement of urine / diarrhea output, vein treatment, ingestion, wound healing and vomiting output (Pickering & Marsden, 2015).

Intervention for Potential Nursing Diagnosis

If a risk is there in terms of impaired integrity of skin, and this is regarded as one of the leading reasons behind stress trauma and skin germs, this is significant to endorse the significance of repositioning as well as usual movement. Patient resilience works for redistributing the pressure all through the body, reducing the risk of stress injury because of the stress on specific parts of the body by chronic stress. Each schedule may vary from patient to patient, as sufficient indication is there for suggesting a complete schedule of repositioning. This allows the patient to move freely in and out of bed. Nevertheless, the responsibility of the nurses is to move the patient to and from bed every two hours and relocate the head and legs of the bed (Miller, Jerosch-Herold, & Shepstone, 2017).

Evaluation of Professional Experience Practice Analysis

The patient was discharged two weeks later in the renal ward. At this period, she lost 10 kg and exceeded his target of 8 kg. This indicates that the nursing intervention reduced the volume of additional fluid volume. The blood pressure of the patient was dropped to an average of 140-150 systoles. In addition, the swelling of her lower limbs could not be fixed entirely. Nevertheless, this meant that leg height was effective in improving swelling, as the legs began to actively cry for serum.

Along with that, skin of the patient remains intact as well as is not damaged by stress after discharge. Patients were positively aware of the importance of posture change and were not required by the nurse. The skin tears present at the hospital have almost completely healed, but a second daily bandage is still not needed for reducing the risk reared to infection.

Moreover, the objectives were realistic after the goals as well as outcomes of the patient were reflected, as well as a number of features were not fully attained within two weeks, but the patient reached near-expected results during discharge (Haesler, 2018).

Conclusion on Professional Experience Practice Analysis

In an attempt to provide potential nursing diagnosis as well as actual nursing diagnosis, the “Nursing Process Framework” was used for developing an interventional nursing care plan, as well as for determining the anticipated consequence of the patient as an outcome of nursing care that is offered to the patient. In addition, the concerned patient is cured as planned and even if all the goals and outcomes of the patient are not met, a significant development in terms of the condition of the patient can be noticed during discharge. Although these improvements ensure the adequacy of this intervention for this particular patient, a beneficial approach was restored by the Nursing Process Framework in an attempt develop the plans of treatment for nursing care.

References for Professional Experience Practice Analysis

Beldon, P. (2013). Back to basics: Correct leg elevation for the oedematous limb. Wound Essentials, 8(1), 68-70.

Boltz, M. (2016). Evidence-based geriatric nursing protocols for best practice (Fifth edition. ed.): Springer Publishing Company, LLC.

Byers, L. A., & Rochon, P. J. (2018). Obstructive Uropathy. In N. A. Keefe, Z. J. Haskal, A. W. Park, & J. F. Angle (Eds.), IR Playbook: A Comprehensive Introduction to Interventional Radiology (pp. 477-487). Cham: Springer International Publishing.

Georgiades, D. (2016). A Balancing Act: Maintaining Accurate Fluid Balance Charting. Aust Nurs Midwifery J, 24(6), 28-31.

Gillespie, B. M., Chaboyer, W. P., McInnes, E., Kent, B., Whitty, J. A., & Thalib, L. (2014). Repositioning for pressure ulcer prevention in adults. Cochrane Database of Systematic Reviews (4). Retrieved from https://doi.org//10.1002/14651858.CD009958.pub2.

Haesler, E. (2018). Evidence summary: Venous leg ulcers: Leg care: Elevation and skin hygiene. Wound Practice and Research: Journal of the Australian Wound Management Association (4), 214. Retrieved from https://ezp.lib.unimelb.edu.au/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edsihc&AN=edsihc.117635652369603&site=eds-live&scope=site.

Jeyapala, S., Gerth, A., Patel, A., & Syed, N. (2015). Improving fluid balance monitoring on the wards. BMJ Quality Improvement Reports, 4(1), u209890.w204102. Retrieved from http://bmjopenquality.bmj.com/content/4/1/u209890.w4102.abstract. doi:10.1136/bmjquality.u209890.w4102

McGloin, S. (2015). The ins and outs of fluid balance in the acutely ill patient. Br J Nurs, 24(1), 14-18. doi:10.12968/bjon.2015.24.1.14

Miller, L. K., Jerosch-Herold, C., & Shepstone, L. (2017). Effectiveness of edema management techniques for subacute hand edema: A systematic review. Journal of hand therapy : official journal of the American Society of Hand Therapists, 30(4), 432-446. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686286/. doi:10.1016/j.jht.2017.05.011

Morris, A., Love, H., Aar, Z. v., Liles, C., & Roskell, C. (2018). Integrating renal nutrition guidelines into daily family life: a qualitative exploration. Journal of Human Nutrition and Dietetics, 31(1), 3-11. Retrieved from https://ezp.lib.unimelb.edu.au/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ffh&AN=2018-05-Aj4508&site=eds-live&scope=site. doi:10.1111/jhn.12483

Pickering, D., & Marsden, J. (2015). Techniques for aseptic dressing and procedures. Community Eye Health Journal(89), 17. Retrieved from https://ezp.lib.unimelb.edu.au/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edsdoj&AN=edsdoj.f377c4af214f4b75acead3e13dedd1cd&site=eds-live&scope=site.

Taskın Yilmaz, F., Sabanciogullari, S., & Aldemir, K. (2015). The Opinions of Nursing Students Regarding the Nursing Process and Their Levels of Proficiency in Turkey. Journal of caring sciences, 4(4), 265-275. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699506/. doi:10.15171/jcs.2015.027

Younas, A. (2017). The nursing process and patient teaching. Nursing made Incredibly Easy, 15(6). Retrieved from https://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2017/11000/The_nursing_process_and_patient_teaching.4.aspx.

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