Nursing Care Plan

Nursing Care Plan
Task 1: Patient assessment
Jim has a temperature reading of 38.3 degrees Celsius and hot skin signifying fever. Normal
body temperature ranges between 36.3-37.3 degrees Celsius. If fever remains unattended, Jim
may complicate with convulsions, dehydration or even shock. Following influenza, infection is
as a result of inflammatory process caused by the virus. Management of fever is by using anti-
pyretics such as paracetamol, tepid sponge baths and treating the cause of infection. In Jim’s
case, he has a viral infection by the influenza virus and treatment is by anti-viral drugs like
oseltamivir (Hsu et al, 2012).
Blood pressure
Jim has a blood pressure reading of 158/86 mmHg. The normal blood pressure reading is 120/80
mmHg therefore Jim has high blood pressure. High blood pressure causes the heart to overwork
in attempt to bring the blood pressure to the normal rate. However, if left untreated high blood
pressure can lead to congestive heart failure where the heart is unable to pump blood per the
body needs, narrowing or thickened blood vessels in the kidney defaulting kidney function,
stroke due to burst weak blood vessels in the brain or even blindness due to burst blood vessels
in the eyes. Management includes regular blood pressure checks and if it persists high inform the
medical team for a prescription of anti-hypertensives (Brown et al, 2017).
Heart rate
Jim has a heart rate reading of 105 beats per minute that is high in comparison to the normal heart rate of 60-100 beats per minute for adults.
Increased heart rate occurs when the heart beats faster even at rest. Tachycardia is brought about following several factors such as an illness
that is known as sinus tachycardia and also by smoking. Jim possesses both reasons to having a tachycardia. He has a history of smoking and
is presenting with symptoms concurrent with influenza therefore an illness. Possible complications following untreated tachycardia include
heart failure, lose of consciousness, myocardial infarction or stroke. In management and control of increased heart rate, encourage Jim to
cease smoking, practice exercise, eat a healthy diet, minimize emotional stress and report to a health facility for regular checkups (Hinkle,
Nursing problem: Example: Risk of spread of infection
Underlying cause or reason: Influenza is a highly contagious virus spread via airborne droplets and direct contact. Immunocompromised patients in the hospital setting are at
higher risk of contracting disease resulting in adverse events.
Goal of care
Nursing interventions/actions
Indicators your plan is working
To prevent and control the
spread of influenza within
the healthcare facility and
the community.
Commence antibiotics.
Start Jim on anti-viral drugs.
Conduct a campaign including
screening of influenza causing virus in
the community.
Administer the fluvax vaccine.
Discourage crowded places.
Practice infection prevention
techniques such as hand washing, use
of gloves and proper waste disposal.
Advise Jim to eat a high protein diet.
Encourage fluid intake.
Recommend deep breathing exercise.
Depletion of signs and symptoms of
infection such as fever.
Testing for influenza for people
presenting with signs and symptoms of
Test negative for the influenza virus
after treatment.
There will be no new cases testing
positive for influenza.
Practice infection prevention
He will not have urinary tract infection.
Prevent pneumonia.
Nursing problem: Self care deficit
Underlying cause or reason: fatigue, malaise and myalgia
Goal of care
Nursing interventions/actions
Indicators your plan is working
To ensure Jim gets through
all the activities of daily
living such as general body
Assist him in bed bathing.
Encourage him to brush his teeth by
providing toothbrush and toothpaste.
Shave or trim Jim’s hair to a
preference or manageable length.
Encourage him to brush his head in
case of a trim.
Jim looks neat and clean.
Jim has no body odour.
He has no lice infestation
Shave his beard.
Provide him with clean gowns.
Assist in bed making.
Nursing problem: Risk of imbalanced fluid volume
Underlying cause or reason: fever
Goal of care
Nursing interventions/actions
Indicators your plan is working
Maintain a balance in the
body fluids.
Administer intravenous fluids.
Encourage Jim to increase the fluid
intake orally.
Commence input output chart.
Assessing the signs of dehydrations
such as dry skin, sunken eyes,
irritability and oliguria.
The input balances the output
Jim appears well hydrated.
Jim is fully conscious and the vital signs
are within normal range.
Will not demonstrate signs of
Nursing problem: knowledge deficit
Underlying cause or reason: lack of facts on influenza.
Goal of care
Nursing interventions/actions
Indicators your plan is working
Empower Jim with factual
data on influenza.
Enquire his understanding of
Outline the predisposing factors, mode
of transmission and management.
Educate him on the availability of
vaccinations against influenza.
Use of teaching aids.
Teach in a quiet environment.
Educate on covering mouth while
sneezing or coughing. Encourage hand
Inform on proper tissue disposal.
He tries to ask questions demonstrating
his understanding.
He answers correctly with facts.
He verbalizes his understanding on
Demonstrates awareness on the
availability of a vaccine and the
importance to receive vaccination.
He will demonstrate more
No occurrence of a newly diagnosed
patient with influenza virus.
Teach him on proper ways to uphold
prevention and control of influenza
Educate Jim on treatment of influenza
outlining possible side effects.
Mention signs and symptoms that may
require medical attention.
No report of an influenza outbreak.
Reduced occurrence of complications.
Nursing problem: ineffective breathing pattern
Underlying cause or reason: inflammation from the infection by the influenza virus
Goal of care
Nursing interventions/actions
Indicators your plan is working
Maintain normal breathing
Monitoring the vital signs frequently
especially the respiration rates.
Pulse oximetry readings.
Administer oxygen for pulse oximetry
readings below 90%.
Position Jim in a propped up position.
Nurse in isolation.
Do chest physiotherapy.
Provide with warm fluids.
Commence oxygenation via nasal
prongs if oxygen saturation levels are
below 90% or according to the
physician’s instructions.
Ensure pain management through
deep breathing exercises.
Nebulization if need be like in
presence of wheezes.
Respiration rates are within the normal
Pulse oximetry reading is 90% and
Jim does not develop breathing
There does not arise new reports of
spread of the virus in the in patients.
He breathes without difficulty.
There are no excretions.
Patient will be able to correctly
demonstrate deep breathing exercises.
Jim will verbalize pain relief and will
appear calmer.
Demonstrates chest expansion without
Task 3: Medication management
Oseltamivir is an anti-viral drug used in treatment of both types A and B of influenza virus. It
acts to inhibit neuraminidase and influenza A and B virus replication in to vitro. Prescription of
oseltamivir is to patients presenting with signs and symptoms of influenza not more than two
days as well as prophylactically for people exposed to the virus. Side effects are rare but include
confusion, delirium, hallucinations and tendency to self-harm. Contraindications of oseltamivir
include children below 2 years, immunodepressed persons, and people with chronic heart, liver
and kidney diseases among others. Oseltamivir is administered orally in capsules or oral
suspension. During prophylaxis, the recommendation is 75 milligrams once per day for 10 days
and 75 milligrams twice per day for 5 days (Fiore et al, 2011).
Fluvax vaccine
Fluvax is the vaccination administered in prevention of the influenza virus infection (Osterholm
et al, 2012). Vaccines work by presenting an antigen enabling the body to create immunity and
boost fight against an antibody. It is given in a dosage of 0.5 millilitres intramuscularly as a stat
dose to persons from age 5 years and above annually. Possible side effect is an allergic reaction.
The reaction is signified by difficulty in breathing, rash, fever and swelling (Fiore et al, 2011).
Paracetamol is a non-steroidal anti-steroidal drug used as an analgesic and anti-pyretic.
Paracetamol acts by inhibiting prostaglandins synthesis. It is either administered intravenously,
orally or intramuscularly. Jim’s prescription is per mouth. Explain to him that the paracetamol
will help eliminate the fever.
Following drug administration, ensure frequent monitor of vital signs including temperature,
blood pressure, respiration rate, pulse oximetry reading and heart rate to detect any deviation
from normal readings. Educate Jim on possible side effects and advise him to communicate in
presence of any of them. Educate Jim on the importance of drug adherence. In case of an adverse
reaction to the drug, inform the medical team immediately. Educate Jim on the importance of
drug adherence to avoid his body from developing resistance to the drug (Smith, Ariano &
Toovey, 2010).
Task 4: Patient teaching
Following positive testing, several lessons to Jim are put into consideration to prevent and
control the spread of the influenza virus infection. The aim of teaching him is to ensure
knowledge on transmission therefore help avoid spread. Control is via vaccination of community
members that have not been vaccinated prophylactically. First, educate him on the importance of
annual vaccination against influenza. Enquire of awareness of people experiencing the symptoms
of influenza to conduct screening to ensure early diagnosis and treatment. Ensure all persons at a
higher risk are vaccinated such as homeless people living in the same street as Jim. It is key to
conduct health campaigns to his neighbourhood on influenza awareness following the positive
result of influenza on Jim. Educate him on the need for good ventilation since it is an airborne
disease. Advise him to avoid crowded areas to prevent spread to other people causing an
outbreak (Grohskopf, 2016).
It is important for Jim to understand the importance of adherence to his medication to ensure
healing and prevent transmission to other people. Educate him on using a handkerchief to cover
his mouth during coughing or sneezing to avoid spreading the virus through droplets. Encourage
frequent hand washing to prevent spread via contact especially following contact with sputum
(Lau et al, 2010).
Task 5: Clinical judgement and handover
Part A
Jim appears to be having an allergic reaction to fluvax vaccine. Inform the medical team
immediately for urgent review. Commence management symptomatically. Jim’s fever is
deteriorating therefore commence management by reducing his clothes, performing a tapid
sponge bath and administering the prescribed antipyretic (Ng et al, 2010). Antipyretic inhibits
the action of prostaglandins in the central nerves system blocking pain reception. Ensure Jim’s
bed is propped up to 45 degrees. Set up intravenous fluids and start the drip to ensure Jim is
hydrated. Following an oxygen saturation level of 86%, set up oxygen and administer 2 litres per
minute via nasal prongs. The oxygen therapy will ensure sufficient oxygen in the circulation.
Prop up Jim’s bed to 45 degrees to maintain a patent airway facilitating breathing. Reassure to
allay anxiety (Blyth et al, 2011).
Part B
Running Head: NURSING CARE PLAN 10
Patient name: Jim
Age: 54 years
Name of staff:
Designation: Registered nurse
Patient admitted with history of dysnea, muscle pains, fatigue, malaise, running nose and
headache for 1 day. He is febrile. He was diagnosed with preliminary influenza. Following a flu
swab, it is confirmed to be type A influenza. He is on oseltamivir 75 mg twice per day for 5
days, fluvax vaccine 0.5 mls intramuscularly and paracetamol.
He is allergic to chicken. He has a history of high blood pressure but not on treatment.
The latest vital signs readings include: temperature-39.6 degrees celcius, heart rat- 125 beats per
minute, respiration rate-24 breaths per minute, saturation rate-96%, blood pressure-139/79
Currently, appears unsettled and has chills.
The medical team has been informed (Klim et al, 2013).
From the assessment, Jim is having an allergic reaction to fluvax vaccine. Continue monitoring
of vital signs and managing symptomatically. Recall the medical team for urgent review.
Continue with Intravenous fluids. Continue with physiological reassurance to allay anxiety
(Thompson et al, 2011).
Running Head: NURSING CARE PLAN 11
Ackley, B. J., & Ladwig, G. B. (2010). Nursing Diagnosis Handbook-E-Book: An Evidence-
Based Guide to Planning Care. Elsevier Health Sciences.
Blyth, C. C., Currie, A. J., Wiertsema, S. P., Conway, N., Kirkham, L. A. S., Fuery, A., ... &
Richmond, P. C. (2011). Trivalent influenza vaccine and febrile adverse events in
Australia, 2010: clinical features and potential mechanisms. Vaccine, 29(32), 5107-5113.
Brown, D., Edwards, H., Seaton, L., & Buckley, T. (2017). Lewis's Medical-Surgical Nursing:
Assessment and Management of Clinical Problems. Elsevier Health Sciences.
Fiore, A. E., Fry, A., Shay, D., Gubareva, L., Bresee, J. S., Uyeki, T. M., & Centers for Disease
Control and Prevention (CDC). (2011). Antiviral agents for the treatment and
chemoprophylaxis of influenzarecommendations of the Advisory Committee on
Immunization Practices (ACIP). MMWR Recomm Rep, 60(1), 1-24.
Gordon, M. (2014). Manual of nursing diagnosis. Jones & Bartlett Publishers.
Grohskopf, L. A. (2016). Prevention and control of seasonal influenza with vaccines. MMWR.
Recommendations and Reports, 65.
Hinkle, J. L., Brunner, L. S., Cheever, K. H., & Suddarth, D. S. (2014). Brunner & Suddarth's
textbook of medical-surgical nursing.
Hsu, J., Santesso, N., Mustafa, R., Brozek, J., Chen, Y. L., Hopkins, J. P., ... & Sæterdal, I.
(2012). Antivirals for treatment of influenza: a systematic review and meta-analysis of
observational studies. Annals of internal medicine, 156(7), 512-524.
Klim, S., Kelly, A. M., Kerr, D., Wood, S., & McCann, T. (2013). Developing a framework for
nursing handover in the emergency department: an individualised and systematic
approach. Journal of clinical nursing, 22(15-16), 2233-2243.
Running Head: NURSING CARE PLAN 12
Lau, L. L., Cowling, B. J., Fang, V. J., Chan, K. H., Lau, E. H., Lipsitch, M., ... & Leung, G. M.
(2010). Viral shedding and clinical illness in naturally acquired influenza virus
infections. The Journal of infectious diseases, 201(10), 1509-1516.
Ng, S., Cowling, B. J., Fang, V. J., Chan, K. H., Ip, D. K., Cheng, C. K., ... & Leung, G. M.
(2010). Effects of oseltamivir treatment on duration of clinical illness and viral shedding
and household transmission of influenza virus. Clinical Infectious Diseases, 50(5), 707-
Osterholm, M. T., Kelley, N. S., Sommer, A., & Belongia, E. A. (2012). Efficacy and
effectiveness of influenza vaccines: a systematic review and meta-analysis. The Lancet
infectious diseases, 12(1), 36-44.
Smith, J. R., Ariano, R. E., & Toovey, S. (2010). The use of antiviral agents for the management
of severe influenza. Critical care medicine, 38, e43-e51.
Thompson, J. E., Collett, L. W., Langbart, M. J., Purcell, N. J., Boyd, S. M., Yuminaga, Y., ... &
McCormack, A. (2011). Using the ISBAR handover tool in junior medical officer
handover: a study in an Australian tertiary hospital. Postgraduate medical
journal, 87(1027), 340-344.

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