GENERAL NURSING MANAGEMENT OF MEDICAL CONDITIONS

GENERAL NURSING MANAGEMENT OF MEDICAL CONDITIONS

APROPHENEMA (AEPROPHENEMA)

AIMS

Facilitate quick healing.
Promote mental, physical, and psychological rest.
Prevent the spread of infection.
Correct electrolyte imbalances.
Prevent complications and restore good health.
Educate the client on the cause, transmission, disease process, and prevention.

To achieve these objectives, the nursing care plan will include the following components:

ENVIRONMENT

The patient will be admitted to a medical ward, preferably in a side ward near the nurses’ station for close monitoring.
Maintain a clean and quiet environment to promote rest and relaxation, aiding the healing process.
Ensure proper ventilation for air circulation and good lighting for observations.
Provide necessary accessories like bedside lockers and cardiac tables for the patient's comfort.
Keep emergency drugs and resuscitation equipment within reach.
For infectious conditions, isolate the patient and adhere to infection prevention measures such as using gloves, aprons, and other personal protective equipment (PPE).

POSITION

The patient will be placed in a position of comfort that does not interfere with treatment.
Use bedrails for restless or unconscious patients to prevent accidental falls.
Reposition the patient every two hours to enhance circulation and prevent pressure sores.
For cardiac or respiratory issues, elevate the head of the bed or use a cardiac table to facilitate lung expansion.

PSYCHOLOGICAL CARE

Explain the condition and treatment plan in simple, clear language to allay anxiety and encourage cooperation.
Allow the patient to ask questions and express fears to reduce tension.
Involve relatives and significant others to foster a sense of belonging and boost the patient's morale.
Maintain privacy during all procedures and respect the patient's preferences.

REST AND EXERCISE

Promote rest during the acute phase of the condition.
Gradually introduce exercises as the patient's condition improves to aid recovery.
Encourage scheduled rest periods to support the healing process.
Perform procedures systematically to ensure the patient has sufficient time to rest.
Minimize noise by reducing visitors, oiling trolley wheels, using rubber shoes, and silencing phones.

OBSERVATIONS

Record vital signs (temperature, pulse, respiration, and blood pressure) at regular intervals to monitor progress:
- Initially every 15 minutes, then every 30 minutes, two hours, and finally every four hours as the condition improves.
Monitor for signs of infection, dyspnea, hypotension, or other complications.
Observe the patient’s general condition, feeding patterns, reaction to hospitalization, and skin turgor to assess hydration.
Check the patency of any tubing or drains.

HYGIENE

Ensure the patient maintains personal hygiene by assisting with daily baths or sponging.
Provide oral care, especially if the patient is bedridden or on oxygen therapy.
Keep linens clean and dry to promote comfort and prevent infections.

NUTRITION AND FLUID

Provide a balanced diet tailored to the patient’s condition to enhance recovery.
Administer fluids orally or intravenously to correct dehydration and maintain electrolyte balance.
Monitor for signs of malnutrition or feeding difficulties, and adjust the feeding route as needed.

ELIMINATION

Ensure regular monitoring of bowel and bladder patterns.
Provide a bedpan or urinal for immobile patients and ensure its proper hygiene.
Address constipation or diarrhea through prescribed treatments and dietary adjustments.

MEDICAL TREATMENT

Administer prescribed medications accurately and monitor for adverse reactions.
Follow the doctor's orders for interventions such as oxygen therapy, IV fluids, or wound care.
Document all treatments and patient responses for ongoing evaluation.

INFORMATION, EDUCATION, AND COMMUNICATION (IEC)

Educate the patient and their family about the nature of the illness, its transmission, prevention, and management.
Provide verbal and written instructions on medication adherence, follow-up visits, and lifestyle adjustments.
Encourage open communication to address concerns and improve compliance.

Step 1: Airway (A)

Assessment:

Is the airway clear?

Can the patient speak?

Are there any airway noises?

Is there air movement?

Management:

Ensure the airway is maintained.

Use suction or postural drainage as needed.

Consider airway manoeuvres (e.g., head tilt, chin lift, or jaw thrust).

Consider the use of airway adjuncts, such as oropharyngeal or nasopharyngeal airways.

Patient Positioning:

Position the patient appropriately to promote airway patency.

Step 2: Breathing (B)

Assessment:

Respiratory rate: Count the breaths per minute.

Respiratory pattern: Observe for normal, shallow, or irregular breathing.

SpO₂: Check oxygen saturation levels using a pulse oximeter.

Chest symmetry: Observe for equal rise and fall of the chest.

Accessory muscles: Look for use of neck or intercostal muscles.

Patient colour: Check for signs of cyanosis or pallor.

Management:

Oxygen therapy: Administer supplemental oxygen if necessary.

Assisted ventilation: Use bag-valve-mask (BVM) or other devices if the patient has inadequate ventilation.

Adjust patient positioning to optimize breathing.

Step 3: Circulation (C)

Assessment:

Manual pulse: Check the rate, rhythm, and quality of the pulse.

Blood pressure: Measure systolic and diastolic pressure.

Colour: Observe skin colour for pallor or mottling.

Capillary refill time: Check peripheral perfusion by pressing on a nail bed and observing the refill time (normal is < 2 seconds).

Management:

Adjust patient positioning to optimize circulation.

Initiate appropriate interventions for circulatory compromise, such as IV fluids or medications.

Step 4: Disability (D)

Assessment:

AVPU scale: Determine the level of consciousness (Alert, Voice responsive, Pain responsive, Unresponsive).

Blood sugar: Check glucose levels.

Pupils: Assess size, symmetry, and reactivity to light.

Pain: Evaluate the presence and severity of pain using a pain scale.

Management:

Provide glucose supplements for hypoglycemia.

Manage pain with appropriate analgesics.

Implement temperature management as necessary.

Perform a FAST assessment (Face, Arms, Speech, Time) for stroke symptoms.

Step 5: Exposure (E)

Assessment:

Perform a thorough head-to-toe examination.

Inspect the patient’s front and back for any signs of injury, abnormalities, or issues.

Management:

Manage any abnormal findings appropriately.

Maintain patient dignity and warmth after exposure.

Key Principle

Scope of Practice: Always assess and treat patients only within your professional scope of practice.

HEAD-TO-TOE ASSESSMENT

1. Introduction

Preparation:

Knock on the door before entering to respect patient privacy.
Perform hand hygiene to minimize infection risk.
Identify the patient using two identifiers (e.g., name and date of birth).
Introduce yourself by name, role, and purpose of your visit.

Explanation:

Clearly explain to the patient what the assessment entails and obtain their consent.
Ensure the patient is comfortable and their privacy is maintained.

2. Neurological Assessment

Orientation:

Ask questions to assess alertness and orientation:

"What is your name?"
"What is your birth date?"
"What day is it today?"

Motor Function:

Ask the patient to perform simple tasks to assess cranial nerves and muscle function:

Smile (facial symmetry).
Stick out their tongue (tongue symmetry and strength).
Shrug shoulders (strength and symmetry of shoulder muscles).

3. Eyes

Pupillary Response:

Use a penlight to assess pupil size, reaction to light, and accommodation.
Ensure pupils are PERRLA:

Pupils Equal, Round, Reactive to Light and Accommodation.

Tracking:

Ask the patient to follow the movement of your finger or pen with their eyes.

4. Neck

Pain or Tenderness:

Ask the patient if they feel any pain or tenderness in the neck area.

Palpation:

Palpate the throat and neck for any abnormalities such as swelling or masses.

Range of Motion (ROM):

Ask the patient to perform neck movements:

"Look side to side (‘no’ motion)."
"Nod up and down (‘yes’ motion)."

5. Arms and Hands

Pulses:

Palpate radial pulses on both wrists to assess circulation.

Capillary Refill:

Press on a fingernail and observe how quickly color returns (normal is < 2 seconds).

Strength:

Ask the patient to squeeze your fingers with both hands to assess grip strength.

Range of Motion (ROM):

Assess joint movement in elbows, shoulders, and hands by asking the patient to perform specific movements.
Look for ease of movement and any pain or stiffness.

6. Chest (Heart and Lungs)

Heart Sounds:

Use a stethoscope to listen at the following landmarks:

Aortic: 2nd intercostal space, right sternal border.
Pulmonic: 2nd intercostal space, left sternal border.
Erb’s point: 3rd intercostal space, left sternal border.
Tricuspid: 4th intercostal space, left sternal border.
Mitral: 5th intercostal space, midclavicular line.

Lung Sounds:

Auscultate both anterior and posterior lung fields.
Listen for breath sounds and note abnormalities like wheezes, crackles, or absence of sound.

7. Abdomen

Observation:

Inspect the abdomen for symmetry, distension, or other abnormalities.

Auscultation:

Use a stethoscope to listen to bowel sounds in all four quadrants.

Palpation:

Gently palpate the abdomen to identify areas of tenderness or masses.

Questions:

Ask about bowel movements (BM): frequency, consistency, and any recent changes.
Inquire about urinary patterns and any issues such as pain or frequency.

8. Legs

Pulses:

Palpate major lower extremity pulses:

Popliteal (behind the knee).
Dorsalis pedis (on top of the foot).
Posterior tibial (inside the ankle).

Capillary Refill:

Assess by pressing on a toenail and observing for color return.

Strength:

Ask the patient to push and pull their feet against your hands to assess muscle strength.

Range of Motion (ROM):

Check joint movement in the hips, knees, and ankles.

Skin Inspection:

Examine the skin for color, temperature, wounds, rashes, swelling, or any other abnormalities.

9. Final Step

Document Findings:

Record all observations, both normal and abnormal, in the patient’s medical record.

Communicate:

Inform the patient about the next steps or interventions based on the findings.
Report significant findings to the appropriate healthcare professional.

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