NUR251 Medical Surgical Nursing 2 - Nursing Care Plan - Assignment Help

Task 1

Firstly, an initial assessment will be completed including - head-to-toe examination, medical history and vital observations related to gathering comprehensive baseline data (Berman et al., 2018). With consent, privacy and ongoing communication, an inspection of the surgery site inclusive of Ruby’s abdomen will be completed. This assessment is necessary to rule out any signs of infection or abnormalities. A wound care chart, observation chart and entry in Ruby’s progress notes and nursing care plan is necessary.

Secondly, a pain assessment will be conducted using the PQRST algorithm (Berman et al., 2018). This assessment is necessary, as providing adequate pain relief will assist in Ruby’s comfort both physically and emotionally (McCabe, 2017). Negligence of this assessment may result in increased pain, distress and reluctance of future nursing care (McCabe, 2017). This assessment will be recorded within the patient observation chart, progress notes and depending on the outcome, the patient medication chart.

Thirdly, a neurological assessment is required to assess Ruby’s level of consciousness and mental status post-anaesthesia using the Glasgow Coma Scale (Tollefson & Hillman, 2016). This also includes communicating with Ruby throughout the initial assessment phases and ensuring adequate responses to questions such as - orientation to person, time and place (Berman et al., 2018). This assessment ensures Ruby is not experiencing any deviations from her normal such as inability to recall recent memory as an adverse post-anaesthesia effect (Berman et al., 2018). A neurological assessment chart will be utilised.

Lastly, the nurse will use a fluid balance chart to assess Ruby’s current fluid input and output. A physical assessment focusing on Ruby’s urine output, skin colour and turgor, peripheral perfusion and mucous membranes will also be completed (Berman et al., 2018). This assessment is necessary as general anaesthetic reduces bladder muscle mobility and suppresses the urge to void (Berman et al., 2018). If this assessment is not completed accurately there is potential for developing life- threatening complications relevant to fluid retention or fluid loss (Berman et al., 2018).

Task 2

 Nursing Care Plan: RUBY SMITH

Task 3

Firstly, it is vital that Ruby understands why she had the subtotal vaginal hysterectomy (abnormal uterine bleeding & chronic pelvic pain) and what the surgery involved (removal of the uterus & fallopian tubes, cervix left intact (Coody, Stutzman & Abraham, 2017)). This information will give Ruby a good indication of her recovery. Ruby’s recovery should involve regular light exercise eg - light 20minute walk 2-3 times per day for one week in increasing time intervals while ensuring adequate rest periods are achieved.

Awareness of the normal signs and symptoms of Ruby’s surgery is also vital (minimal blood loss, mild-moderate abdominal pain) and that any abnormal signs (fever, swelling, increased blood loss, severe abdominal pain) require immediate medical attention to reduce chances of future illness’/complications (Berman et al., 2018). The nurse should provide a leaflet that can be placed on Ruby’s fridge outlining the normal versus abnormal signs and symptoms of her surgery. Attendance to follow-up appointments is also essential and organising reminders should be encouraged on Ruby’s calendar/phone with medical details for easy access.

Thirdly, competent hygiene practice is imperative in reducing risk of infection as well as assisting in the healing process. Ruby can implement daily cleans, both morning and evening using soap-free warm water. It would also be advisable to avoid bathing and showering for long periods, wear loose fitting/breathable clothing, avoid sitting in the same position for prolonged periods, change pads 2-4 hourly and avoid sweating and over-activity (Berman et al., 2018).

Task 4

10/08/2018 – 2030 – Nursing handover and patient received at 1330.

Ruby is alert and orientated to person, place and time. Ruby has positively contributed to nursing care throughout the shift. Ruby’s observations were attended 4/24 – all within normal parameters. 1500 – Ruby reported 8/10 pain, pain assessment was initiated and IMI fentanyl 100mcg was administered at 1515, Ruby stated 3/10 pain 1530 with minimal wincing and complaints observed. Pain has been under control with paracetamol 1g QID and IMI ketorolac 30mg TDS. Urine output has been maintained at >30ml/hr with nil signs of fluid imbalance/dehydration on 2/24 fluid assessments. FBC is stable. Initial strategy to increase mobilisation discussed. Ruby demonstrated eagerness through regular

independent repositioning and stated that “I feel better moving rather than lying in bed all day”. Ruby requires x1 assistance with ADL’s. Skin intact. Nil signs of pressure injury on inspection. Guarding, tenderness and minimal swelling present on abdominal examination. Surgical site is clean, nil signs of infection/abnormalities present at 1800. Demonstration provided for cleansing of surgical site. Ruby is tolerating food/water. Nil nausea/vomiting. Continent – nil patient complaints. Ruby had family present all day and was actively participating in conversation. Ruby speaks highly of her families ongoing support on several occasions – nil signs of anxiety...............................……………………………………………