Vital Signs Assessment And IV Cannula Assessment In Nursing Care

Question: Discuss about the Vital Signs Assessment And IV Cannula Assessment. Answer: Priority nursing assessments to determine Johns nursing care During nursing care, the followingnursing assessments should be conducted on John; wound assessment, vital signs assessment, and IV cannula assessment(Ginger, 2016). After receiving Johns report from the ward nurse the first thing to do is to assess the IV cannula site, for signs of infections, because it is an artificial opening into the blood system that can easily carry infections if not used aseptically(Davidson, 2016), also inspect it for patency to determine if he needs a new one or not and assess how long it has stayed in situ, because the longer it has stayed the higher the chances of getting an infection. Johns vital signs that is blood pressure, respiratory rate, temperature, pulse rate, heart rate, oxygen saturation rate, pain score, alertness, and urinary output should be given priority during assessment, because they are the earliest indicators of an infection and how well the physiologic processes are taking place, they should always be within the normal range. Wound as sessment is another priority assessment; the wound is assessed for signs of infection and exudation because they indicate the healing process. Necessity for nursing care John requires totalnursing care because he has cellulitis and bacterial infection from the wound. He is on Intravenous medication with gentamycin which should be monitored carefully due to nephrotoxicity and the wound should be monitored as it heals to minimize complications. He also has a history of chronic anxiety, which should be monitored, because it can recur due to bacterial infection, cellulitis and hospitalization. Consequences of incomplete assessment Incomplete assessment can lead to complications of the infection, incomplete wound healing and development of acute tubular necrosis due to gentamycin which is a nephrotoxic agent. Explain why was John prescribed Gentamycin 300mg IV TDS and Ibuprofen 400mg oral TDS Gentamycin was prescribed to John because it is a broad spectrum antibiotic and its active against most gram negative organisms including Proteus species, Pseudomonas which can result to nosocomial infections. Gentamycin is enough to cover John for the bacterial infection, cellulitis and is a prophylactic against pseudomonas which can result to a nosocomial bacterial infection leading to complications. It is administered through IV because it will be highly effective through that route of administration(M, 2016). Ibuprofen is prescribed because it is a non-steroidal anti-inflammatory drug, used for treating pain fever and inflammation. John will be experiencing pain due to the wound, fever due to the bacterial infection and inflammation as a result of the wound and the body healing mechanism. Ibuprofen will be used to minimize the effects of inflammation, which are pain, fever and tenderness(Reed, 2017). Identify and explain nursing responsibilities associated with administration Of these medications The nurses responsibility is to ensure adherence and assess for effectiveness of the medication and their side effects. Gentamycin is associated with nephrotoxicity and ototoxicity among other side effects such as nerve damage, low blood count allergic responses and neuromuscular problems. The nurse should assess the patient for signs of adverse reaction, through physical assessment, urinary output and urine analysis. Ibuprofen has the following adverse effects pruritus, bronchospasms, constipation, dyspepsia, and diarrhea, increased risk of liver failure heart failure and kidney failure and gastrointestinal bleeding and high blood pressure. The nurse should be on the look-out for these effects through physical assessment andnursing assessment of the patients condition daily. The nurse has to note that kidney failure and nephrotoxicity are side effects of both medications and they can superimpose on each other worsening the condition; therefore frequent urine analysis and urinary output is vital to monitor the patency of the renal system. Nursing assessment on deterioration Due to the deteriorating state of the client expressed by increased heart rate, increased systolic blood pressure, an increased respiratory rate and a slightly reduced body temperature indicates side effects of the medication, additional assessments that the nurse should do perform are urinary output and urine analysis to assess the kidney function in-case of adverse effects of the medications and perform a hearing assessment to isolate the extensiveness of the adverse effects. Also perform a wound assessment and IV cannula site assessment, to assess for any sign of infection from the outside. My conclusions from the signs and symptoms would be an adverse reaction from the medication or an infection from either the wound site or the IV cannula site. Maybe the IV cannula had overstayed and the client has sustained and infection which can result to the increased heart rate and respiratory rate, and worsened by the medications. Another conclusion can be an anxiety attack, because John has a history of chronic anxiety, which can be worsened by the disease process. Nursing interventions The patient should be assisted back the bed and propped up to aid in respiration(Butcher, 2018). Also give diazepam to manage anxiety that might occur as a result of the disease process or the medication interaction leading to physiologic changes, and take a swab of the wound for laboratory diagnosis to isolate any cause of infection(Sherwood, 2017). Also monitor the urinary output and urine analysis for renal functions. Document all of the procedures done to the patient in the patient file(Kerr, 2013). John condition could be prevented if someone was with him during the30 minutes when the medication was running, to evaluate his response to the medication and any other factors that could have worsened his anxiety, also someone should have assessed the IV cannula site for patency. Patient education during discharge planning On discharge educate the patient on the importance of adherence to medication both the antibiotics and anxiolytics and daily wound dressing to prevent the wound from becoming septic and to encourage healing. Emphasize on the importance of bed rest, to allow the wound to heal and teach on signs and symptoms of anxiety and how to avoid the triggering factors. Finally tell the patient that they can get information from the hospital website. On discharge counsel the patient on lifestyle modification, with a low-sodium diet because of the side effects of medication(Peter, 2015). Bibliography Butcher, H. (2018). Nursing Interventions classification (NIC)-E-Book. Elsevier Health Sciences. Davidson, M. (2016). Teaching aseptic techniqueApplying the basics. Infection, Disease Health, 21(3), 139. Ginger, J. (2016). Transcultural Nursing-E-Book: Assessment and Intervention. Elsevier Health Sciences. Kerr, D. (2013). Bedside handover enhances completion of nursing care and documentation. Journal of nursing care quality, 28(3), 217-225. M, A. (2016, May). Topical application of intra-sternal Vancomycin and subcutaneous Gentamycin significantly reduces deep sternal wound infection after cardiac surgery. In WIENER KLINISCHE WOCHENSCHRIFT, 28. Peter, D. (2015). Reducing readmissions using teach-back: enhancing patient and family education. Reducing readmissions using teach-back: enhancing patient and family education., 45(1), 35-42. Reed, G. (2017). Effect of Aspirin on the Cardiovascular, Gastrointestinal, and Renal Safety of Celecoxib, Naproxen, or Ibuprofen. Sherwood, G. (2017). Quality and safety in nursing: A competency approach to improving outcomes. John Wiley Sons.