Nursing Care Plan | EssayIvy.com

Running Head: NURSING CARE PLAN 1

Nursing Care Plan

Name

Date

NURSING CARE PLAN 2

Task 1: Patient assessment

Temperature

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).

NURSING CARE PLAN 3

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,

2014).

Running Head: NURSING CARE PLAN 4

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

Rationale

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.

 To kill the bacteria and prevent

multiplication.

 To kill the virus and avoid further

multiplication.

 To access spread of the virus and

possibility of an outbreak.

 To help destroy the influenza virus.

 Influenza is airborne therefore to

prevent transmission.

 To prevent spread of the virus.

 To boost immunity

 Increase micturition preventing

urinary tract infection

 To promote chest expansion and

help clear secretions (Hsu et al,

2012).

 Depletion of signs and symptoms of

infection such as fever.

 Testing for influenza for people

presenting with signs and symptoms of

influenza.

 Test negative for the influenza virus

after treatment.

 There will be no new cases testing

positive for influenza.

 Practice infection prevention

techniques.

 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

Rationale

Indicators your plan is working

To ensure Jim gets through

all the activities of daily

living such as general body

hygiene

 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.

 Ensure his body is clean to

minimize body odours, clean body

fluids such as sweat.

 Ensure oral hygiene.

 Ensure a clean head and prevent

lice infestation and look

presentable.

 Jim looks neat and clean.

 Jim has no body odour.

 He has no lice infestation

Running Head: NURSING CARE PLAN 5

 Shave his beard.

 Provide him with clean gowns.

 Assist in bed making.

 Prevent lice invasion on the beard

as well as attain a neat look.

 To eliminate body odours (Gordon,

2014).

Nursing problem: Risk of imbalanced fluid volume

Underlying cause or reason: fever

Goal of care

Nursing interventions/actions

Rationale

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.

 Avoid fluid imbalance.

 Early diagnosis and management

of fluid imbalance.

 Prevent Jim from going into shock.

 Promote early hydration and

prevent shock (Gordon, 2014).

 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

dehydration.

Nursing problem: knowledge deficit

Underlying cause or reason: lack of facts on influenza.

Goal of care

Nursing interventions/actions

Rationale

Indicators your plan is working

Empower Jim with factual

data on influenza.

 Enquire his understanding of

influenza.

 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

washing.

 Inform on proper tissue disposal.

 Measure the information he has

on influenza,

 Clear up misconceptions

associated to the flu.

 Promote Jim’s understanding of

influenza.

 To promote control and

prevention of the disease.

 To promote memory.

 To minimize disruptions.

 To minimize spread.

 To prevent outbreaks.

 He tries to ask questions demonstrating

his understanding.

 He answers correctly with facts.

 He verbalizes his understanding on

influenza.

 Demonstrates awareness on the

availability of a vaccine and the

importance to receive vaccination.

 He will demonstrate more

understanding.

 No occurrence of a newly diagnosed

patient with influenza virus.

Running Head: NURSING CARE PLAN 6

 Teach him on proper ways to uphold

prevention and control of influenza

virus.

 Educate Jim on treatment of influenza

outlining possible side effects.

Mention signs and symptoms that may

require medical attention.

 To ensure early management of

side effects preventing

complications (Gordon, 2014).

 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

Rationale

Indicators your plan is working

NURSING CARE PLAN 7

Maintain normal breathing

pattern

 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.

 Readings out of the normal rates

indicate respiratory insufficiency

therefore inadequate oxygenation.

Normal respiration rate for adults

is 15 to 18 breaths in a minute.

 A pulse oximetry reading below 90

% indicates insufficient oxygen in

blood.

 To supplement the inadequate

oxygen in the blood circulation.

 To maintain the airway patent.

 To prevent spread of the virus.

 To promote chest expansion

during breathing.

 To assist get rid of excess sputum

maintaining a clear airway.

 Prevent hypoxia.

 Pain leads to reduced respiratory

effort therefore poor ventilation.

Raises anxiety.

 Prevent lung overload and collapse

(Ackley & Ladwig, 2010).

 Respiration rates are within the normal

range.

 Pulse oximetry reading is 90% and

above.

 Jim does not develop breathing

difficulty.

 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

difficulty.

NURSING CARE PLAN 8

Task 3: Medication management

Oseltamivir

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

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).

Running Head: NURSING CARE PLAN 9

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

mmhg.

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

Reference

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 influenza—recommendations 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-

714.

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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