Table of Contents
Assessment of Patient.
Plan and target the patient.
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.
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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).
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 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.
Intervention in actual nursing diagnosis
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).
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).
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.
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