Nursing assessment Essay Example | Topics and Well Written Essays - 500 words

Nursing assessment - Essay Example Having noted all the foregoing findings, the three immediate nursing actions for Miss Jones would be: 1) To assess causative and precipitating factors, 2) to evaluate degree of excess fluids and 3) to promote mobilization/elimination of excess fluids (Doenges, Marilyn E., Moorhouse, Mary Frances, pp. 224-225. Assessing the causative and precipitating factors will involve the anticipation of cardiac failure, so it is essential to regularly monitor her breathing along with oxygen level infusion. Aside from this, the fact that a rapid infusion of IV fluids could transpire, the drip rate of the patient’s IV fluids must be checked constantly and adjusted to normal limits (Olsen, June Looby, Giangrasso, A.P., 2000). All fluid intakes must be noted as to its source and volume. Similarly, the amount of sodium and potassium intake must be observed and noted in relation to ingested food, drugs and IV infusion. The second immediate nursing intervention is: to evaluate degree of excess fluids present within the individual. This second nursing action requires constant monitoring of vital signs (Medline Plus, 2007) to observe whether a change has occurred from the last charting schedule. of any related complications that may occur. In relation to this, the present weight of Monica Jones must be compared to previous stated or admission weight since increase of weight could indicate that fluid is being retained in the body. Regular auscultation of the lungs for the presence of crackles must be done and charted during this phase of intervention to see whether the crackling sounds that were previously heard have increased or diminished. Recording the occurrence of dyspnoea is equally essential within this secondary phase of nursing intervention, to note whether hard labour breathing is continuous or takes place only when triggered by an environmental stimuli. In accordance with