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NUR250 Medical Surgical Nursing

Published : 27-Sep,2021  |  Views : 10


Explain the specific underlying cause/s (aetiology) or reason/s for each of the nursing problems above.Briefly explain why Neville has been prescribed:
o Oral prednisone
o ipratropium bromide via nebuliser
o Oral amoxicillin

Identify and explain
o The specific nursing responsibilities associated with administering each medication and monitoring Neville for expected, side and adverse effects 
How to effectively use a metered dose inhaler (MDI) and spacer
Why he needs to stop smoking
Early indicators that his COPD is deteriorating that require medical review
Promoting adequate nutritional intake to meet his metabolic needs
Energy conservation strategies
Identify the specific information you will need to explain to Neville about the topic Explain
o Why the topic is an important aspect of Neville’s care
o How you will ensure that Neville knows and understand why it is important and, if appropriate to the topic, what he needs to do.


Based on the case study  the identified nursing problems are:

  • Ineffective airway clearance-It is evident from cough and increased sputum production, which  led to severe obstruction in pulmonary path. Increased difficulty in breathing even after admissionwas due to ineffective airway clearance (Burt & Corbridge, 2013),
  • Impaired gaseous exchange- occurs due to incomplete release of carbon dioxide or excess oxygenation at the alveolar-capillary Nivelle had pulmonary obstruction and increased sputum production due to which he had poor gaseous exchange. Due to excess trapped air the patient suffered shortness of breath and dysapnoea. This condition also made him tachycardic and elevated his blood pressure(Kim & Criner, 2013).
  • Risk of impaired ventilation- Due to impaired gaseous exchange, Nivelle is at higher risk for perfusion inequality(Matkovic & Miravitlles, 2013). He was suffering from cold and the preventive medications did not seem to relieve the symptoms. Nivelle remains tachycardic with high blood pressure. Due to persistent shortness of breath on mild exertion, his nasal prong oxygen remains in place as his oxygen saturation level was below 90%. 
  • Imbalanced nutrition-The patient is experiencing acute respiratory distress. In addition, current medication, dyspnoea, and increased sputum production had increased the risk of anorectic conditions. The patient is having poor diet due to pulmonary obstruction and shortness of breath on exertion even after admission.Nivelle, is having poor diet due to this condition and his body is not meeting its basic metabolic requirements adequately. He was ordered to push oral fluids and had high requirement of protein and carbohydrates. Consequently, it led to nutritional imbalance (Hsieh et al., 2016).
  • Risk for infection-Being COPD patient, Nivelle’s innate immune system is very weak. This impaired immune system makes him highly vulnerable to infection in respiratory tract. Due to inadequate first line of defence the patient has reduced ciliary secretions increasing the susceptibility of bacterial colonisation (Matkovic & Miravitlles, 2013). Further, malnutrition added to this vulnerability and acute exacerbations. 

Nursing Care Plan:   Neville 

Note:  Dot points recommended in care plan.   Click and type in each cell, click enter in a cell to make it longer

A reminder that all information must be referenced

Nursing problem: To keep the patient safe

Underlying cause or reason: In patients with COPD, due to low oxygen saturation , the patient may be unsafe


Goal of care

Nursing interventions/actions


Indicators your plan is working

Ensure patient safety

Ensure patient achieves required level of oxygen saturation and prevent breathing difficulty.


1.Correct equipment care

2.Back up oxygen system in case of power failure

3.Teach patient on proper use of oxygen and prescription instructions

4. Use of portable oxygen concentrators



It prevents oxygen saturation to decrease below 90%.  It prevents condition of hypoxemia (Corrado et al., 2016).

Oxygen concentrators prevent the necessity to carry oxygen with them (Uronis et al., 2015).

Oxygen saturation of 88-90% achieved.

Nursing problem: dehydration

Underlying cause or reason: Neville is at greater risk of dehydration. It will increase the viscosity of secretions. Fluid balance is essential to increase in pressure on diaphragm. It helps aid in gastric distension.

Goal of care

Nursing interventions/actions


Indicators your plan is working


To prevent dehydration by maintaining the fluid balance   and keeping him hydrated



Adequate intake of fluid before, during after meals. Push fluid orally and maintain the fluid balance chart.  Give oral warm fluid  to the patient


 increase the optimal functioning if the body. Increase in expectoration with warm fluid. Warm fluid decreases the thickening of the mucus lining in the lungs and promotes clearance (Ghosh et al., 2015).


Normal input and output, Reduced distress and irritation in patients is indicative of appropriate hydration.

Nursing problem: Malnutrition and therefore need to fed

Underlying cause or reason: There is an increase in resting energy expenditure as the patient has to put effort while breathing. Patient has dyspnoea which increases difficulty in swallowing and sometimes alteration of taste  due to mouth breathe

Goal of care

Nursing interventions/actions


Indicators your plan is working

To fed the patient for nutrition needs and help Neville to gain weight

Assess the nutritional needs

Assess the food intake, dietary behaviour (Melo, Albuquerque & Aragão, 2012)

Maintain  oral fluids and modify diet balanced diet of protein, carbohydrates and fat.

During anorexia caused by the respiratory distress, extra calories are required (Bailey et al., 2012).

Increase in body weight

Nursing problem: Poor mobility  

Underlying cause or reason:

Neville’s condition is very serious with poor intestinal integrity and is unable to perform activities of daily living independently. Shortness of breath  decreases his mobility.

Goal of care

Nursing interventions/actions


Indicators your plan is working


Improve mobility to improve activities of daily living and quality of life of the patient

1.Explain the tripod position to Neville, that is how stand or sit leaning forward and forcing the diaphragm downwards and stabilising the chest (Brien et al., 2016)

2. Explain how to support arms during ADLs

3.Help in pacing activities and use of assistive devices

4. Exercises and breathing techniques – pursed lip breathing and controlled expirations


1.Reduce the work of breathing

2. Supporting arms when performing daily activities reduces demand for neck and chest muscles and arms when breathing. It will reduce dyspnea development (Rutten et al., 2014)

3.Help in energy conservation and improve mobility

4. Reduce respirations and prevents narrowing of airway

 Patient will be able to walk or stand without difficulty patient does not indulge in strenuous activities, it indicates of careful implementation of the plan. Improved breathing is evidence of effective coping.

Nursing problem: Risk of infection  

Underlying cause or reason: In the case study, Nevlle is highly susceptible to infection as he has long history of smoking, which is sure to exacerbate the COPD symptoms and destroy the lung function. In addition, he is also prone to infections by indoor and outdoor pollution. Other risks that may hamper patient safety are nutritional and emotional distress and lower economic status.

Goal of care

Nursing interventions/actions


Indicators your plan is working

To ensure that the patient is clean and dressed


1. Ensure that the patient’s belongings, clothes living area are free of dust or pollution both at hospital and in home after discharge  

2.Regulary monitor the vital signs

 Pollution will increase comorbidities in patient and rate of infection. Infection is indicated by change in vital signs such as temperature.  


Normal vital signs and no indicatefever, allergy found.

 Medication management 

Neville is administered with oral prednisone. This medicine has anti-inflammatory effect.  It is a glucorticoid and has been found effective in enhancing the lung function. It may reduce repeated admission of Nevelle. The medicines administered to Nevelle  is ensured that they are cost effective and are affordable by the family members. It is also effective to minimise the allergic reactions and immune disorders. However, the medication has contraindication that the patient may be hypersensitive to this drug (Abroug et al., 2014). It is the responsibility of the nurse to ensure patient safety. Hence, the side effects will be regularly monitored which include heartburn, depression, sore throat, increased sweating, thirst and acne. While administering this medicine, the patient and his family will be informed about the necessary diet modification and exercise program to improve the symptoms more quickly (Spencer & Hanania, 2013). 

Ipratropium bromide as nebuliser is used to control and reduce shortness of breath due to COPD. This drug helps the airways to open up so that the obstruction is cleared. It helps in muscle relaxation by inhibiting the effect of acetylcholine and inducing the cholinergic effect (Obeidat et al., 2016). The side effect of the medication include constipation, dryness of mouth, or and sudden worsening of breathing. Prior to administering this medicine it will be ensured that the patient is not allergic as this drug has the potential to interact with non-prescription drugs. Moreover, this medicine needs to be administered regularly for effective results. 

Oral amoxicillin is administered as Nevile is highly susceptible to bacterial infection in current situation. This medication needs intake of plenty of fluids. The patient will be educated about the contraindications such as gastrointestinal pain, irritation of eyes, nausea and vomiting which may occur as side effects of oral amoxicillin. There are adverse effects if used for prolonged period. This drug is found to have interactions and hence will be closely monitored (Brusse-Keizer et al., 2015).

While administering this medication it will be ensured that appropriated dosage will be given as recommended by the physician and take the approval of the doctor prior to change of dosage as a part of professional communication (Scotten et al., 2015).

Patient teaching 

Neville requires a nurse led education program on smoking cessation. Health literacy is essential for patients to better manage their illness (Kawayama et al., 2016). Nevelle is required to be explained on how smoking exacerbates the COPD symptoms. Smoking increases severity of airway obstruction. Smoking destroys the air sacs and the inner lining of the lungs along with inflammation (Sewell et al., 2014). Increased trapped air increases respiratory distress due to increased sputum production and thickening of airways. It eventually worsens coughing and exacerbations to an extent that may impair his mobility. Even mild exertion may lead to difficulty in breathing. Neville can be educated by means of videos and providing other educating materials illuminating on deteriorating quality of life  due to COPD and how smoking decreases the rate of survival (Stellefson et al., 2014). Thus, smoking cessation is an important aspect of Neville’s care. 

The patient’s understanding of the topic will be confirmed once he complains of unable to restrain from smoking. This is first step of taking initiative to cease smoking. It indicates that the patient had understood the consequences of smoking and decreasing life expectancy. The patient can be referred to motivational interviewing and regular counselling sessions to ensure smoking cessation. It will help Neville to stay firm in his decision. Cognitive behavioural therapy, rehabilitation and psychoanalytical approaches have been successful in preventing people from smoking, alcohol abuse and other addictions (Krishnan-Sarin et al., 2013). Since Neville’s wife is supportive, she must be educated on the adverse effects of illness, necessity of on time medication, and lifestyle modification needed for her husband.

Clinical judgement and handover

 In this situation it appears that Neville is experiencing the side effects of administered salbutamol nebuliser. It was prescribed due to elevated blood pressure and tachycardia. However, this medication was not justified due to contraindication that it is not administered when patient is having tachyarrhythmias (Albertson et al., 2013). The patient was not aware of it and he was given salbutamol nebuliser on his request. He is currently administered with oral prednisone, ipratropium bromide, and oral amoxicillin. 

The nursing interventions in this situation (Jellington et al., 2016) are-

  • Assessment of lungs sound and vital signs- to ensure proper functioning of lungs
  • Check ECG and pulse rythm- Since patient already had high blood pressure and tachycardic
  • Increase brightness of light in room and rise bed rails-to reduce restlessness in patient and provide comfortable breathing
  • Monitor auscultation of the lungs to identify bronchospasms 


  • Registered nurse appointed to care for patients with pulmonary disorders
  • Nivelle is a 62 year old man admitted with established COPD
  • Patient had history of excessive smoking


  • Improvement in upper respiratory symptoms
  • Shortness of breath and dyspnea
  • Tachycardia
  • High blood pressure
  • Malnutrition
  • Nnasal prong remains in place
  • Currently administered with oral prednisone, ipratropium bromide, and oral amoxicillin

 Patient was admitted with worsening dyspnoea, cough and increased sputum production

  • Excessive smoking history
  • Persistent cough and cold
  • Low respiratory rate
  • Shortness of breath on exertion
  • Unable to take more than few steps before rest
  • Tachycardia and high blood pressure

 Agreed plan-

The patient has established moderate chronic obstructive pulmonary disorder (COPD)

  • Continue nasal prong oxygen @ 2L/min
  • Maintain oxygen saturation between 88-92%
  • spirometry before and after nebulisers
  • Diet to prevent malnutrition
  • Continue with current medication
  • Administer Pneumococcal and flu vaccines prior to discharge

 Read Back- 

Patient and family needs must follow up with attending physician and registered nurse for optimising treatment. A healthy lifestyle modification in addition to smoking cessation is required (Scotten et al., 2015).


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