NUR250 Medical Surgical Nursing 1

Question:

Topic:

Nursing care of a patient with a medical condition

Purpose

Developing the ability to locate, interpret, integrate, synthesize and apply nursing knowledge to a relevant nursing practice scenario in medical surgical settings.

Assessment 1: Case scenario one

Identify:	Mr Peter Jones, HRN: 123456, DOB: 26/03/1958
Situation:	Peter is a 61 year old Indigenous man from a remote community.
	He has been admitted to the CDU medical ward with chest pain. He
	has a 6/24 history of central crushing chest pain. His ECG shows
	that he has suffered from and inferior NSTEACS (NSTEMI).
Background:	Peter lives in a single story home with his wife, 4 children and 2
	grandchildren. He is independent with his cares.
	He has an extensive past medical history including:
	T2DM, smoker (10 per day), HTN, hyperlipidaemia, rheumatic
	heart disease and mitral valve regurgitation.
	No known declared allergies (NKDA).
Assessment:	Airway: Own, patent
	Breathing: RR 22, Sats 94% on RA.
	Circulation: HR 96 bpm, BP 160/95 mmHg.
	Disability: GCS 15/15, 4/10 central chest pain, feels tired and a bit
	worried.
	Exposure: Temp 37.0 oC
Recommendations/Read	Medical orders
back:	•	Repeat ECG

	•	Pain management
	• TED stockings and DVT prophylaxis
	Medication orders
	New medications:
	• GTN sublingual spray 400mcg PRN
	• Oral paracetamol 1g QID
	•	Aspirin 300mg STAT
	•	Clopidogrel 300mg STAT
	Usual medications:
	• Metformin XR 1gm BD
	•	Ramipril 10mg OD
	•	Simvastatin 20mg OD

Assessment 1: Case scenario two

Identify:	Mrs Rose Wilson, HRN: 123678, DOB: 19/02/1962
Situation:	Rose is a 57 year old Caucasian lady from Darwin. She has been
	admitted to the CDU medical ward with exacerbation of COPD. She
	has a 2/7 history of dyspnoea, productive cough and a fever.
Background:	Rose lives in a two story home with her husband. She is
	independent with her cares.
	She has a past medical history of:
	T2DM, smoker (20 per day), HTN, hyperlipidaemia and obesity.
	No known declared allergies (NKDA).
	She is obese (BMI 30) and drinks 1 bottle of wine every night.
Assessment:	Airway: Own, patent
	Breathing: RR 26, Sats 89% on RA.
	Circulation: HR 89 bpm, BP 160/95 mmHg.
	Disability: GCS 15/15, 2/10 sharp chest pain on inspiration
	Exposure: Temp 38.6 oC
Recommendations/Read	Medical orders
back:	• Chest X-ray ordered

	• Administer medications as charted
	•	Pain management
	• TED stockings and DVT prophylaxis
	Medication orders
	New medications:
	• Oral paracetamol 1g QID
	•	Ceftriaxone 1g BD
	•	Amoxycillin 1g TDS
	Usual medications:
	• Metformin XR 1gm BD
	•	Simvastatin 20mg OD
	• Salbutamol MDI 100 mcg PRN
	• Seretide MDI; 1 puff BD

Assessment 1 Tasks:

Choose from one of the patients handed over to you. Using the template provided in the Assessment 1 folder and, based on the handover you received at the beginning of your shift today, other information included below and current reliable evidence for practice, address the following tasks.

Task 1: Consider the patient

Based on the case scenario and in grammatically correct sentences:

Define the patient’s condition.

Discuss the pathophysiology of the disease.

How does the condition link with the patient’s past medical history?

Task 2: Care plan

Based solely on the handover you have received and using the template provided, complete a nursing care plan for your chosen patient. Your plan must address the physical, functional and psychosocial aspects of care.

Three nursing problems have been provided for you. For each nursing problem on your care plan you need to complete the following sections:

What it is related to?

Goal of care

Interventions

Rationales for interventions

Evaluation

Task 3: Patient education: Discharge planning

An important aspect of nursing practice is to effectively and succinctly communicate relevant information related to ongoing disease management or prevention of reinfection or deterioration on discharge.

Patient education and discharge planning starts on admission and you need to provide your patient with education during your shift in preparation for discharge home.

Explain two important points/topics you will need to include in the patient’s preparation for discharge to aid healing and prevent further illness.

For each education point identified provide:

One strategy to assist the patient to implement the education into their daily routine.

Task 4: Medication

Choose two medications that your patient has been prescribed (one (1) from their new medications list and one (1) from their old medications list) and discuss the following:

How does the medication work?
Why has your patient been prescribed this medication?
Are there any red flags/drug interactions that could affect the patient?
Use the clinical guidelines provided to support your claim.

Answer:

Task 1

By considering the physical health condition of Mrs Wilson, it is observed that the chief complaints related hindering her physical wellness is an exacerbation of COPD. COPD is demarcated as a group of disease commonly used to describe lung disease which includes chronic bronchitis, emphysema and refractory asthma (McCarthy et al., 2015). The chief illness observed in case of patient suffering from COPD is shortness of breathing. Apart from that, she is also experiencing cough and fever and also has a history of dyspnea. Upon verifying her medical background, it has been observed that she has a past medical history type 2 diabetes mellitus, hyperlipidemia and obesity. The patient is not found to be allergic to any drugs. The vital signs of the patient are assessed which shows that airway of the patient is transparent and open, breathing rate of the patient is 26 which is more than that of the reasonable respiratory rate (12 bpm) and air saturation is 89%. Heart rate and blood pressure of the patient has also been found to be elevated to 89 bpm and 160/95 mmHg. The glasscoma scale test has also been performed to evaluate any symptoms of injury where the patient scored 15/15, which means that patient does not possess any signs of brain injury and the body temperature of the patient is also within normal range (38.6 degree Celcius) (Reith, Van den Brande, Synnot, Gruen & Maas, 2016).

By reviewing the case study of Mrs Wilson, it has been observed that the patient is suffering COPD exacerbation. COPD exacerbation is defined as the episode of COPD where the breathing of a person becomes worse, and as a result, they struggle to maintain the Oxygen level. COPD minimizes the functionality of the lungs by effecting the air sacs and airways. Usually when a person inhales air, it travels to the bronchial tubes that are the airway of the lungs through windpipe and is distributed in thinner channels named as bronchioles, and as a result the air sacs filled with air and the sacs deflate during expiration. However, in case of COPD, the air sacs and the airway lose their stretchiness and create hindrance during inspiration. The air sacs walls get damaged, and the airway becomes inflamed as well as thickened. As a result the airway secretes more mucus and forms clog which obstructs the flowing in and out of the airways (Lareau, Fahy, Meek & Wang, 2019).

The previous medical history observed in the case of Mrs Wilson is hypertension, hyperlipidaemia, T2DM and obesity. Along with it, the patient was also a smoker which is one of the major causes behind the occurrence of COPD as regular intake of tobacco possesses a negative impact on the airways and air sacs of lungs also in the patient suffering from hypertension have an increased risk of exacerbation of COPD. According to the research conducted by (Gill et al., 2016), increased level of glucose in diabetes enhances the rate of lung infection me and also plays a vital role in worsening the symptoms of COPD.

Task 2

Nursing Care Plan: (Mrs Rose Wilson)

Nursing problem: Acute Pain
Related to: Chest, shoulder, lower back and neck pain is commonly observed in the case of a patient suffering from COPD.
Goal of care	Nursing interventions	Rationale	Evaluation
The patient will determine her current pain level as an acceptable level of pain.	The patient is repositioned to fowler position and along with that nitro-glycerine is administered sublingually (Lee, Harrison, Goldstein & Brooks, 2015).	Repositioning helps the patient to maintain airflow and administration of Nitro-glycerine will relax heart arteries so that blood can flow easily (Lee, Harrison, Goldstein & Brooks, 2015).	Pain is tested by the help of pain rating scale, and it is expected that the pain score of the patient is below the acceptable level.
Nursing problem: Risk of ineffective tissue perfusion
Related to: obesity, chronic obstructive pulmonary disease, diabetes and high blood pressure, which affect the air exchange between the blood and the cells and as a result, the cells do not get adequate oxygen.
Goal of care	Nursing interventions	Rationale	Evaluation
Reducing the risk of ineffective tissue transfusion.	The patient is assisted with position changes by the assistance of the nurse.	Position changes are one of the most effective and commonly used methods in nursing inpatient suffering from tissue transfusion. Repositioning a patient from the supine position to sitting or standing position helps in reducing the risk of tissue perfusion (Garabedian, Kelly & Landreville, 2017)	Evaluation is done after implementing an intervention for the stipulated period. In this case during evaluation, Symptoms of ineffective tissue perfusion are assessed and are supposed to be minimised after the treatment.
Nursing problem: Anxiety
Related to: It has been observed that many individuals suffering from Chronic obstructive pulmonary disease experiences anxiety due to the indication of danger possess by acute symptoms of COPD.
Goal of care	Nursing interventions	Rationale	Evaluation
To reduce anxiety to avoid further risk of the panic attacks.	Encourages the client to involve in relaxation exercise such as guided imagery, deep breathing, progressive muscle and meditation (Dreyer et al., 2015).	Anxiety is commonly observed in the patient suffering from any chronic illness due to pain and other effects. By encouraging the patient to involve in relaxing exercise, muscles are relaxed. Relaxations of muscles are one of the most effective non-chemical ways to minimize anxiety by calming brain.	After evaluating the intervention it is supposed that the health condition of the patient is enhanced. In this case, as the primary issue stated is anxiety, after the intervention, it must be reduced. The patient is demonstrated to return to basic skill for problem solving.

Task 3

Discharge planning is demarcated as the interdisciplinary approach to the continuity of care and a procedure which includes identification, goal setting, assessment, planning, implementation, evaluation and coordination even after the patient leaves the hospital. The primary aim of discharge planning is to prepare the patient for leaving the hospital. Discharge planning is linked with discharge education which aims to improve the health outcome of the patient by delivering quality care. Along with information related to the patient’s health condition such as, cause for hospitalization, procedures, findings, treatment and outcome, recommendation for maintaining future wellness is also added (Gonçalves?Bradley, Lannin, Clemson, Cameron & Shepperd, 2016).

By reviewing the case study of the patient, it is observed that involving in physical activity and taking self-care is one of the most important topics that need to be incorporated in the discharge planning of the patient. It will not only speed the recovery process of the patient but will also aid in the prevention of further illness.

Involving in physical activity: According to the research conducted by Burge, Cox, Abramson & Holland (2017), physical inactivity in patient having the higher risk of getting affected with the pulmonary disease increases the threat of COPD exacerbation and as a result lead to hospitalization. Exacerbation related hospitalization occurred due to poor physical activity can also lead to mortality. Involvement in physical activity strengthens the lungs and heart muscle by improving the body’s ability to use oxygen. In patient suffering from COPD physical exercise involving upper part of the body is recommended as it can help in strengthening the respiratory muscle.

Self-care: Apart from physical activity, self-care strategies are one of the most effective methods to improve mental and physical wellness in the patient suffering from COPD. Self-management strategy includes proper nutrition, medication, and involvement in physical activity, coping skills and medication adherence (Matarese, Barbaranelli & Riegel, 2019).

To encourage patient to adapt to the above mentioned strategy, it is important to educate them about the strategy with which they can implement the modification in their life (Williams and Hopper, 2019).

For physical activity exercises are,

Walk until it becomes difficult to breathe,
Riding a stationary bike
Doing sit-ups
Holding legs in the front me and then putting down
Measuring oxygen level in the regular interval with oximeter
Pulmonary rehabilitation is also suggested.

In addition to creating awareness about the strategies, the patient is also educated about the effectiveness of physical activity in reducing the risk of Chronic Obstructive Pulmonary Disease. It will help the patient to maintain an oxygen level as required according to the health of the patient (Donaire-Gonzalez et al., 2015).

Strategies for self-care:

Keeping lungs healthy from getting further damaged
Monitor a healthy diet such as eating smaller meals throughout the whole day.
Stay away from the risk factors such as fumes, smokes and odours.
Staying away from smokers as it increases the risk of COPD infection.

Stay away from impurities and infections such as pneumococcal infections by washing infection and stay away from the crowds.

The patient is also educated about the effectiveness of self-care that enhances the recovery process and also assist in threat of future illness in the patient (Harrison, Janaudis-Ferreira, Brooks, Desveaux & Goldstein, 2015).

Task 4

Usual medication:

Metformin XR 1gm BD

After reviewing the previous medication list of the patient, it is observed that the patient is taking Metformin in order to manage the blood glucose level. It belongs to a class of medicine knows as biguanide. When metformin is administered in the body, it reduces the amount of glucose in the blood by lowering the amount of glucose secreted from the lever and along with that also enhances the sensitivity to insulin in the muscle cells. In a diabetic patient, it assists by restoring the proper response of the body to insulin which is naturally produced in the body.

In the above case of Mrs Wilson, Metformin XR 1gm BD is prescribed for the proper management of diabetes as it helps to control high blood pressure. It is commonly prescribed in patient suffering from Type 2 Diabetes mellitus in order to prevent blindness, nerve complications, kidney damage, loss of limbs and sexual function complications. In the patient, it also reduces the risk of heart complications in patient suffering from COPD (Rena, Hardie & Pearson, 2017).

Drugs interactions might possess a negative impact on the stipulated action of the particular drug. When metformin interacts with the other beta blocker medication it possesses impact on heart by preventing the past or the pounding heartbeat usually observed when the blood glucose level falls down (Lemone et al., 2017). Along with this, other symptoms such as hunger, dizziness or sweating of the lowering of blood glucose level is also remaining affected when interaction between metformin and beta blocker medication occurs (He & Wondisford, 2015). There are other medications also noted which can affect the mode of action of the drugs and make it harder to control the blood glucose level. Hence it is advised for the patient to consult with the doctor before taking any medication to reduce the risk of further infection.

New medication

Oral Paracetamol 1g QID

Paracetamol belongs to the class of acetaminophen usually prescribed in the patient suffering from fever reducer and pain reliever. The exact mechanism of action is not known completely (Straus et al., 2018). The paracetamol is used to treat muscle aches, backache, fever, cold, arthritis, toothaches, and headache. Apart from that, it is also used for other illness which is not clearly known. According to the (), paracetamol should not be prescribed in patient suffering from liver disease or have a previous medical history and also in the case of pregnant women or if breastfeeding a baby. Paracetamol possesses central analgesic effects which are mediated by the activation of serotonergic pathway. The exact mode of action of paracetamol is unknown. During fever, pyrogen a protein is secreted from the body, which increases the synthesis of a compound named as prostaglandin in hypothalamic region which raises the temperature stipulated point. By the administration of Paracetamol, the synthesis of Prostaglandin is inhibited (Chiumello, Gotti & Vergani, 2017).

In the above case of Mrs Wilson, she has been suffering from fever and cough or cold. To reduce the adverse impact of fever and cough, paracetamol is prescribed to the patient.

Paracetamol interacts with a number of drugs and produces major, moderate and minor drug effects such as, enhances the risk of getting affected with other illness. When paracetamol is administered it should be kept in mind that it should not be taken along with the other medication consisting paracetamol. It increases the risk of overdose (Sharma & Trout, 2015).

References

Burge, A. T., Cox, N. S., Abramson, M. J., & Holland, A. E. (2017). Interventions for promoting physical activity in people with COPD. Cochrane Database of Systematic Reviews, (4). https://doi.org/10.1177/0163278719873960

Chiumello, D., Gotti, M., & Vergani, G. (2017). Paracetamol in fever in critically ill patients—an update. Journal of critical care, 38, 245-252. https://doi.org/10.1016/j.jcrc.2016.10.021

Donaire-Gonzalez, D., Gimeno-Santos, E., Balcells, E., de Batlle, J., Ramon, M. A., Rodriguez, E., … & Ferrer, A. (2015). Benefits of physical activity on COPD hospitalisation depend on intensity. European Respiratory Journal, 46(5), 1281-1289. DOI: 10.1183/13993003.01699-2014

Dreyer, N. E., Cutshall, S. M., Huebner, M., Foss, D. M., Lovely, J. K., Bauer, B. A., & Cima, R. R. (2015). Effect of massage therapy on pain, anxiety, relaxation, and tension after colorectal surgery: A randomized study. Complementary therapies in clinical practice, 21(3), 154-159. https://doi.org/10.1016/j.ctcp.2015.06.004

Garabedian, R. J., Kelly, A. C., & Landreville, S. K. (2017). U.S. Patent No. 9,757,188. Washington, DC: U.S. Patent and Trademark Office. Retrieved from: https://patents.google.com/patent/US9757188B2/en

Gill, S. K., Hui, K., Farne, H., Garnett, J. P., Baines, D. L., Moore, L. S., … & Tregoning, J. S. (2016). Increased airway glucose increases airway bacterial load in hyperglycaemia. Scientific reports, 6, 27636.https://doi.org/10.1038/srep27636

Gonçalves?Bradley, D. C., Lannin, N. A., Clemson, L. M., Cameron, I. D., & Shepperd, S. (2016). Discharge planning from hospital. Cochrane database of systematic reviews, (1). https://doi.org/10.1002/14651858.CD000313.pub5

Harrison, S. L., Janaudis-Ferreira, T., Brooks, D., Desveaux, L., & Goldstein, R. S. (2015). Self-management following an acute exacerbation of COPD: a systematic review. Chest, 147(3), 646-661. https://doi.org/10.1378/chest.14-1658

He, L., & Wondisford, F. E. (2015). Metformin action: concentrations matter. Cell metabolism, 21(2), 159-162. Retrieved from: https://link.springer.com/article/10.1007/s00125-017-4342-z

Lareau, S. C., Fahy, B., Meek, P., & Wang, A. (2019). Chronic Obstructive Pulmonary Disease (COPD). American journal of respiratory and critical care medicine, 199(1), P1-P2. Retrieved from: https://www.atsjournals.org/doi/pdf/10.1164/rccm.1991P1

Lee, A. L., Harrison, S. L., Goldstein, R. S., & Brooks, D. (2015). Pain and its clinical associations in individuals with COPD: a systematic review. Chest, 147(5), 1246-1258. https://doi.org/10.1378/chest.14-2690

Lemone, P., Burke, K., Bauldoff, G., Gubrud, P., Levett-Jones, T., Hales, M., … Reid-Searl, K. (2017). Medical-surgical nursing, Critical thinking for person-centred care. (3^rd ed.). Melbourne, Victoria: Pearson Australia.

Matarese, M., Barbaranelli, C., & Riegel, B. (2019). Reply to Comment on: Self-Care Evaluation in COPD. Evaluation & the health professions, 0163278719873960. https://doi.org/10.1016/j.ctcp.2015.06.004

McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., & Lacasse, Y. (2015). Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane database of systematic reviews, (2). https://doi.org/10.1002/14651858.CD003793.pub3

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 medicine, 42(1), 3-15. https://doi.org/10.1007/s00134-015-4124-3

Rena, G., Hardie, D. G., & Pearson, E. R. (2017). The mechanisms of action of metformin. Diabetologia, 60(9), 1577-1585. https://doi.org/10.1016/j.cmet.2015.01.003

Sharma, M., & Trout, B. L. (2015). Effect of Pore Size and Interactions on Paracetamol Aggregation in Porous Polyethylene Glycol Diacrylate Polymers. The Journal of Physical Chemistry B, 119(25), 8135-8145.

Straus, S. E., Glasziou, P., Richardson, W. S., & Haynes, R. B. (2018). Evidence-Based Medicine E-Book: How to Practice and Teach EBM. Elsevier Health Sciences.

Williams, L. S., & Hopper, P. D. (2015). Understanding medical surgical nursing. FA Davis.

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