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Medical Surgical Nursing : Vital Signs Charts

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Medical Surgical Nursing : Vital Signs Charts

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Medical Surgical Nursing : Vital Signs Charts

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Question:
Describe about the Medical Surgical Nursing for Vital Signs Charts.
 
Answer:
1. It is necessary to diagnosis and nursing care according to the chart because these vital signs charts enable a person to know if the body homeostasis is functioning properly or not, like the respiratory rate and the temperature of the body. These sign are important for the nurse because these signs make possible for the nurse to find out whether the patient is responding well or not to the treatment provided to the patient by the nurse. In this case, the sign chart explains that a problem is remaining in the Sonya’s health condition and therefore she still requires a nursing care (Hooton, 2010).
 
If the documentation is not completed accurately then there will a wrong interpretation of the signs will occur which will ultimately result in a wrong treatment. A wrong treatment can produce an overreaction of the body towards the drugs due to the immune response. This immune response can be very serious and if not dealt with in time it could be fatal.
It is not even possible to treat the patient at all if the urinalysis chart is not completed accurately because the documentation provides the information about the type of renal and urinary condition that is present in the patient. It cannot be identified whether the patient is having kidney stone or a urinary tract infection without the accurate data or documentation.

Goal of care

Nursing interventions/actions

Rationale

Indicators your plan is working

Void in normal amount of urine and with a usual pattern
 
 
 
 
 
 
 
 

Observing Sonya’s urine amount and noting the voiding pattern

If the patient is suffering from calculi the pattern will not be uniform since the urge to urinate increases as the stones nears ureterovesical junction (Girard et al., 2015)

Voiding normal amount of urine with a normal pattern
 

Voiding normally without retention of urine

Measuring the patient’s inputs and outputs hourly and starting the patient on antibiotic therapy(Vanacomycin intravenous)according to the prescription

Provide suitable measures like massage for increasing the relaxation and reducing the tension in the muscles (Gulanick & Myers, 2013).

Administer  regular and break through analgesics as charted

2. Nursing care Plan for Sonya

Goal of care

Nursing interventions/actions

Rationale

Indicators your plan is working

Minimize pain on movement and urination
 
 

1.      Assess pain using pain score and PQRST algorithm
2.      Monitor for observational pain signs facial expressions, guarding and impaired movement
 

To describe, evaluate, and document the pain of the patient in a correct manner.
 
To look for the vital signs and other impairments and check for any contraindications such as unconsciousness, nausea, delirium and vomiting.
 

Sonya states pain has improved
Pain score is low or zero
 
 
Sonya appears comfortable with no signs of guarding or facial grimacing.
 
 

Checking the input and the output in every eight hours and should monitor the results of the repeated urinalysis (Oman et al., 2012).
 

Administer  regular and break through analgesics as charted
 

To describe, evaluate, and document the pain of the patient in a correct manner.
 

Sonya verbalizes minimal pain on urination
 

Checking for any contraindications such as unconsciousness, nausea, delirium and vomiting.
 

Administer regular and break through analgesics as charted (Oman et al., 2012).
 
 

To explain the procedure to the patient. If possible, they should also assist the patient in sitting position and stay until the patients swallow the medicine

Sonya is relaxed does not have the  the feeling of pain (Girard et al., 2015).
 
 

Divert the attention of the patient in the given case scenario to make her relax and to avoid the feeling of pain.
 

Provide non-pharmacological interventions – heat packs, warm shower and position (Gulanick & Myers, 2013). 
 

To describe, evaluate, and document the pain of the patient in a correct manner (Doenges et al., 2016).

Sonya is mobilizing freely with normal gait
 

Checking for any contraindications such as unconsciousness, nausea, delirium and vomiting.
 

Discuss with medical team the use of a urinary alkaliniser to reduce stinging on urination (Girard et al., 2015).
 

Administer regular and break through analgesics as charted (Oman et al., 2012).
 
 
 

Sonya is responding to the suitable measures like massage for increasing the relaxation and reducing the tension in the muscles.
 

For oral analgesics, the nurses should confirm the diagnosis as well as age of the patient.

To describe, evaluate, and document the pain of the patient in a correct manner (Gulanick & Myers, 2013). 

To improve the symptoms of the disease (Oman et al., 2012).
 
 

Sonya is giving a positive response regarding the administration of   regular and break through analgesics as charted
 

The nurse should also provide suitable measures like massage for increasing the relaxation and reducing the tension in the muscles

Checking for any contraindications such as unconsciousness, nausea, delirium and vomiting (Gulanick & Myers, 2013). 

For reducing the pain and eliminating the acidic content of the urine and monitoring the voiding pattern(Oman et al., 2012).
 
 

Sonya is showing the improvement due to the suitable measures for increasing the relaxation and reducing the tension in the muscles

Monitor for observational pain signs facial expressions, guarding and impaired movement
 

Assist the patient in sitting position and stay until the patients swallow the medicine (Oman et al., 2012).
 

Administer  regular and break through analgesics as charted
 

Sonya is comfortable in sitting position and can swallow the medicine easily
 

Checking the input and the output in every eight hours and should monitor the results of the repeated urinalysis (Oman et al., 2012).
 

Administer  regular and break through analgesics as charted
 

To improve the symptoms of the disease (Gulanick & Myers, 2013). 
 
 

Sonya is relaxed and does not have the feeling of pain
 

Provide suitable measures like massage for increasing the relaxation and reducing the tension in the muscles

Provide patient education  about expected pain levels for this condition (Doenges et al., 2016).
 
 

To improve the symptoms of the disease
 

Sonya is mobilizing freely
 

Checking for any contraindications such as unconsciousness, nausea, delirium and vomiting.
Void in normal amount of urine and with a usual pattern (Girard et al., 2015).
 
 

To describe, evaluate, and document the pain of the patient in a correct manner
 
Observing Sonya’s urine amount and noting the voiding pattern (Oman et al., 2012).
 

Administering  regular and break through analgesics as charted
 
If the patient is suffering from calculi the pattern will not be uniform since the urge to urinate increases as the stones nears ureterovesical junction (Girard et al., 2015)
 

Sonya appears comfortable with no signs of guarding or facial grimacing
 
Sonya states that her symptoms are improving

Voiding normally without retention of urine

Measuring the patient’s inputs and outputs hourly and starting the patient on antibiotic therapy(Vanacomycin intravenous)according to the prescription

Provide suitable measures like massage for increasing the relaxation and reducing the tension in the muscles (Gulanick & Myers, 2013).

Sonya feels a bit comfortable with respect to the symptoms of her disease.

3. Sonia has been prescribed analgesics orally because analgesics for relieving the symptoms of pain. Analgesics act on the peripheral as well as central nervous systems of the body for blocking or decreasing the sensitivity towards pain. While some of the other analgesics works by inhibiting the formation of some chemicals that mediates pain in the body.
She was prescribed vancovmycin intravenously because it will be helpful in the treatment of the Urinary Tract Infection (UTI) of the patient. It works by inhibiting the bacterial growth.
Hartman’s 1000mls over 12 hours is prescribed for replacing the fluids and, minetrals of the body of a number of medical reasons (Doenges et al., 2016).
The nursing responsibilities associated with administering the three medications/ fluid concerns the following;
For administering vancomycin intravenous, the nurse should administer the injection by vein as prescribed by the doctor. The dosage of vancomycin is based on the medical condition, response to the treatment, weight and other vital functions. It is used for treating the infections in the different parts of the body. It is mainly administered for severe infections, which cannot be treated with the help of medicines (Butcher et al., 2013).
For oral analgesics, the nurses should confirm the diagnosis as well as age of the patient. There is also a need to check the medication purpose and review the record for the dose, which has been given previously (Elkin, Perry & Potter, 2003). They should check for any contraindications such as unconsciousness, nausea, delirium and vomiting. They also need to explain the procedure to the patient. If possible, they should also assist the patient in sitting position and stay until the patients swallow the medicine (LeMone et al., 2015).
For administering Hartmann’s solution, the nurses should use an intravenous drip and it can be administered at different rates depending on the specification and necessity. If in case, it is administered in excessive amount then the patient may have swollen hands, feet and ankles due to retention of fluids (Baird, 2015). 
For assessing or monitoring, the patient to ensure that she is responding appropriately to these three medications/fluids, which have been administered, the nurses will make a comparison with the normal with the abnormal consequence of drug administration. The effects of each of these medications or fluids will be monitored for reaching to a conclusion that whether the patient in the given scenario needs other medications for her recovery.
 
4. From the signs and symptoms of the patient in the given case scenario, it can be concluded that her symptoms have aggravated, as it is evident that her Glasgow Coma Scale was 14 confused and disoriented, her heart rate was found to be 135bpm irregular and thready, oxygen saturation was 96% on Hudson mask@6L, and respiratory rate is 26bpm. There is a presence of verbal groans only. The temperature of the patient was found to be 39.90C. The cannula of her right arm revealed signs of inflammation. Thus, from these symptoms, it can be established that the condition of the patient is getting worsened.
The current condition of Sonya signifies the problem, which she is facing because of her urinary tract infection and renal symptoms. These symptoms are the main causes of her deteriorating condition. The patient in the given case scenario also had a past medical history of renal calculi, hypertension and hyperlipidaemia but she has not been able to tolerate the regular medications. It has also been revealed that she is allergic to medicine. She did not respond to regular paracetamol, lethargy and nausea with intermittent vomiting. All these symptoms have aggravated her conditions (Dubois et al., 2013).
5. The ISBAR framework signifies a consistent approach for communication, which can be utilized in any situation or circumstance. It stands for Introduction, situation, Background, Assessment, and Recommendation. The nurse taking care of the patient in the given case scenario needs to monitor the changes in the colour of her urine, monitoring the voiding pattern. The nurse should check the input and the output in every eight hours and should monitor the results of the repeated urinalysis (Perry, Potter, & Ostendorf, 2015).  The rationale for this implies to the indications of the progression or deviations from the predictable results. The nurse should also note the location as well as time of the intensity scale. She should also help the patient in the given case scenario for evaluating the place of impediment as well as cause of the pain. The nurse should also provide suitable measures like massage for increasing the relaxation and reducing the tension in the muscles. The patient in the given case scenario should also be provided with perineal care for preventing urethra contamination. If the nurse is using a catheter, then the catheter can provide a way for the bacteria for entering the urinary tract and the bladder. The nurse should also divert the attention of the patient in the given case scenario to make her relax and to avoid the feeling of pain. She should also give the analgesics for controlling the pain (Juvé‐Udina et al., 2014).
 
6. As a nurse, my experience regarding the care plan of the patient is concerned with past and the present condition of the patient in the given case scenario. The care plan aims to improve the symptoms of her disease and make all the symptoms normal. While developing the care plan, the things that were easy for me is to provide mental support to the patient. The things which were challenging for me was in controlling the pain and managing the symptoms of the patient. It took additional time for understanding the main concerns of the patient, and administering the medications in a proper way.
 
I can apply this nursing care plan framework to provide nursing care for the individuals in the clinical setting particularly to the patients suffering from Urinary tract infections. This plan addresses the physical, functional and psychosocial aspects of care. The plan has provided suitable measures such as massaging to enhance the relaxation reduce the muscle tension. The care plan aims to improve the symptoms of her disease and make all the symptoms normal. The plan also contains the rationales behind the the nursing interventions or actions for the management of the symptoms of Urinary Tract Infection in an efficient manner.
 
References
Baird, M. S. (2015). Manual of critical care nursing: nursing interventions and collaborative management. Elsevier Health Sciences.
Butcher, H. K., Bulechek, G. M., Dochterman, J. M. M., & Wagner, C. (2013). Nursing interventions classification (NIC). Elsevier Health Sciences.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales. FA Davis.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing diagnosis manual: planning, individualizing, and documenting client care. FA Davis.
Dubois, S., Larue, C., Dubé, V., Bérubé, M., & Gélinas, C. (2013). [Project evaluation of nursing interventions: an algorithm to support the practice of clinicians]. Recherche en soins infirmiers, (112), 88-93.
Elkin, M. K., Perry, A. G., & Potter, P. A. (2003). Nursing interventions and clinical skills.
Girard, R., Gaujard, S., Pergay, V., Pornon, P., Gaujard, G. M., Vieux, C., … & Group, U. T. I. C. (2015). Controlling urinary tract infections associated with intermittent bladder catheterization in geriatric hospitals. Journal of Hospital Infection, 90(3), 240-247.
Gulanick, M., & Myers, J. L. (2013). Nursing care plans: nursing diagnosis and intervention. Elsevier Health Sciences.
Hooton, T. M. (2012). Uncomplicated urinary tract infection. New England Journal of Medicine, 366(11), 1028-1037.
Juvé‐Udina, M. E., Pérez, E. Z., Padrés, N. F., Samartino, M. G., García, M. R., Creus, M. C., … & Calvo, C. M. (2014). Basic nursing care: retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting. Journal of Nursing Scholarship, 46(1), 65-72.
LeMone, P., Burke, K., Dwyer, T., Levett-Jones, T., Moxham, L., & Reid-Searl, K. (2015). Medical-surgical nursing. Pearson Higher Education AU.
Lo, E., Nicolle, L. E., Coffin, S. E., Gould, C., Maragakis, L. L., Meddings, J., … & Yokoe, D. S. (2014). Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infection Control & Hospital Epidemiology, 35(S2), S32-S47.
Oman, K. S., Makic, M. B. F., Fink, R., Schraeder, N., Hulett, T., Keech, T., & Wald, H. (2012). Nurse-directed interventions to reduce catheter-associated urinary tract infections. American journal of infection control,40(6), 548-553.
Perry, A. G., Potter, P. A., & Ostendorf, W. (2015). Nursing interventions & clinical skills. Elsevier Health Sciences.
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2016). Fundamentals of nursing. Elsevier Health Sciences.
Urden, L. D., Stacy, K. M., & Lough, M. E. (2015). Priorities in critical care nursing. Elsevier Health Sciences.

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