Nursing Management of the Patient with a Complex Condition Assessment 2022

Nursing Management of the patient with a complex condition
Introduction
Nursing management of the patient with complex condition based on the evidence based
literature improves the clinical knowledge of the nurse (Vaughan 2016). The clinical scenario
chosen for the assessment is case 3. Mr.paul peter is 45years old man presented with
complaints of not feeling well and sustained wound on his left leg.
Systematic assessment
Central nervous system
Nursing assessment of the central nervous system begins with the assessment of the
conscious level. The patient is conscious and alert. He is emotionally stable. His reasoning
ability is good. He scores 15/15 in the Glasgow coma scale. He has no history of head injury
and neurological surgery. He opens the eyes spontaneously. He is able to perceive
communication well. He responds to verbal communication. He is oriented to the place,
person, circumstances and occasion. He is able to remember the latest and old memories. He
is able to move his upper and lower limbs. Reflexes are present. Senses are present and
normal. On the assessment of intellectual knowledge, he has basic information about general
knowledge since the patient had completed 7th grade in primary school.
The cardio- vascular system
The patient has no history of cardiac disease and surgery. Thorax is symmetrical. Have no
complaints of any palpitations and chest pain. On inspection have no sign of central cyanosis
and peripheral cyanosis. On palpation the temperature is normal. Has no scar, skin
discolouration, lumps or wound over the chest region has no skin discolouration over the
chest region. On Auscultation rate regularity and beat are normal. His heart rate is increased
120/mt. has no abnormal heart sound. On palpation, the size of the heart is normal and has no
enlargement. His radial pulse is elevated 112/mt. His blood pressure is 90/60 mmHg. His
ECG is normal.
Respiratory system

The patient has no past and present medical history of respiratory problems. He is a smoker
for the past 30 years. He smokes one packet of cigarette a day. On observation he has no scar,
skin discolouration, lumps or wound over the chest region. The chest has no deformity. Chest
movement is bilateral and symmetrical. Respiration rate, regularity and breathing pattern are
normal. Have no complaints of cough or sputum production. Air entry is normal. Patient’s
nails and skin has no cyanosis. On auscultation breath sounds are normal and have no
abnormal sounds. The complete expansion of both lungs is present. Respiratory rate is 24/mt.
On palpation position of thorax and trachea are normal. Have no complaints of cough,
sputum production and breathlessness.
Gastro-intestinal system
The patient has no past and present medical history of abdominal disorders and surgery.
Patient verbalises that he has normal appetite and his bowel movements are normal. Has no
melena and blood stained stool. He empties his bowels twice daily. He has no history of
abdominal pain. His food intake is normal. On inspection shape and size of the abdomen is
normal, umbilicus is normal. Has no abdominal distension. Has no skin discolouration. On
auscultation his bowel sounds are normal. Palpation was done on the four quadrants of the
abdomen to rule out abnormalities. There is no enlargement of abdominal organs like liver,
spleen and gallbladder. Have no complaints about the altered biological cycle, nausea,
vomiting, diarrhoea, constipation, and regurgitation.
Urinary system
The patient has no past and present medical history of urinary infection. Has no history of
surgery in Genito-urinary tract. On inspection patient’s urine output is normal. Urine is dark
in colour, has strong smell and has no pus and blood particles in urine. Have no complaints of
burning sensation or pain on urination. Urinanalysis results are normal. On palpation over the
lower abdomen, there is no mass or lump are present. Kidneys and bladders are normal in
size. Patient voids 5-6 times in the day and 1-2 times in night. The patient has no complaints
of any nocturia, polyuria, hematuria or incontinence.
Skin assessment

The patient has no past medical history of skin infections or diseases. On inspection the skin
is moisture and looks hydrated. Have no lesions, scars, and rashes in the skin. Has no changes
in skin pigmentation and has no discolouration of the skin. The patient has a wound to his left
leg for past two weeks. He got hurt when he went fishing. The wound is inflamed with green
exudates. He has complaints of pain on the wound site. Pain is measured using pain scale
which scores 5/10.
Priorities of treatment
Wound care
Assessment
Assessed the wound for bleeding, pus discharge, exudates and smell of the exudates. On
assessment, the patient has wound to his left leg for the past two weeks. He got hurt when he
went fishing. The wound is inflamed with green exudates which indicate that the wound is
infected and need immediate attention. He has complaints of pain on the wound site. Pain is
measured using pain scale which scores 5/10
Nursing Interventions
Clean the wound and apply the dressing (Armstrong 2017). Use proper hand washing
technique. Restrict visitors and allow one assistant to be with the patient. Continuously
monitor the pain using pain scale. Educate the patient about personal hygiene and
demonstrate the hand washing technique to the patient and patient assistant (Drahnak 2016).
Report the wound condition to the doctor. Administer analgesic for pain. Advice the patient
that, increased intake of alcohol delays the wound healing. Advise the patient to increase the
fluid intake and also the importance of fluid intake in sepsis. Educate the patient about the
importance of nutritious food for wound healing. Reassure the patient. Administer antibiotic
as per doctor’s prescription (Eckmann 2016).
Evaluation
Patient’s wound looks clean and shows signs of healing. Patient and his assistant are using
proper hand washing technique. Only a few visitors visit Mr.paul. He is taking high protein

and high fibre diet. Patient’s fluid intake is increased and patient verbalises that he is feeling
better now.
Documentation
Documented the appearance and the characteristics of wound. Information about Wound care
and dressing are documented. Maintained intake output chart and vital signs chart. Patient
education on personal hygiene, hand washing technique is documented. Documented the
administration of the antibiotic.
Reduce pain
Assessment on the case of Mr.paul reveals that he s suffering from pain for the past two due
to the wound and related infection. He is presented with an open wound with inflammation
and green exudates. He is diagnosed with sepsis. It is the responsibility of the nurse to plan
the nursing interventions to reduce pain and promote the comfort for the patient.
Nursing Interventions
Continuously assess the pain using pain scale. Assess the intensity and location of the pain.
Position the patient comfortably with extra pillows and cushions. Administer analgesics as
per doctor’s order. Educate the patient on pain management techniques. Reassure the patient
and provide diversion therapy. Advise the patient to increase the fluid intake. Educate the
patient the high protein diet heals the wound fast. Encourage the patient to do deep-breathing
exercise. Assist the patient in mobilisation and educate the patient about the importance of
mobilisation in wound healing (Bloos 2017). Support the wound with dressing which reduces
the pain. Administer analgesics as per doctor’s order (Bartley 2015).
Evaluation
Patient verbalises that his pain s reduced. The patient is benefited by diversion therapy and
pain management techniques. The patient is co-operative and actively participating in pain
management nursing care. The patient is aware of the importance of mobilisation in wound
healing. He has increased the fluid intake and taking a high protein diet.
Documentation

Documented the findings of continuous monitoring of pain. Documented the administration
of antibiotics. Patient education on pain management is documented. Documentation is done
on the increased fluid intake and high protein diet. Documented the mobilisation of the
patient.
Initiate investigations
Assessment
The patient is presented with complaints of illness and abnormal vital signs. He is presented
with wound on his left leg with inflammation and pain. He is suffering from the wound and
sepsis for the past two weeks the immediate nursing assessment for Mr Paul is to analyse the
level infection on continuous monitoring (Gotts 2017).Order for the urine and blood
investigations to rule out the intensity of infection and the organisms causing infection
(Kleinpell 2017).
Nursing Interventions
Do urine and blood investigations to rule out the intensity of infection. Do blood culture to
rule out the organism or group of organism causing infection and the appropriate antibiotic to
treat the infection (Shetty 2018). Continuously monitor the patient’s vital signs every half an
hour to rule out the condition of the patient. Watch for conscious level. Administer IV fluids
as per doctor’s order (Chang 2016). Use proper hand washing technique. Monitor the
patient’s temperature. Continuously monitor the pain using the pain scale.
Evaluation
Continuous monitoring of vital signs aids the nurse to observe the changes in the vital signs
and patient’s condition. On administration of antipyretics, the patient’s temperature became
normal. On administration of analgesics patient’s pain is reduced. His pain scores 3/10.
Documentation
Documentation on the initiation of investigation is done. Documented the vital signs and IV
fluid administration. Documented the patient’s level of consciousness and pain.

Prevention of infection
Assessment
Assessment reveals that the patient’s vital signs are elevated due to sepsis. Patient’s blood
pressure is 90/60mmHg which may be caused by the severity of the infection and
dehydration. Abnormal vital signs indicate that the patient is at risk and needs immediate
treatment. The intensity of the internal sepsis is revealed by the vital signs (Bloos 2017).
Nursing interventions
Continuously monitor the temperature. Apply non-pharmacological nursing interventions if
the patient tolerates. Advise the patient to increase the fluid intake. Monitor intake and output
chart watch for signs symptoms of fluid imbalance. Switch on the fan if patient has no chills
or cold. Continuously monitor the patient’s heart rate. Check for any other associated
symptoms. Monitor the respiratory rate. Watch for the signs and symptoms of infection of
vital organs (Shetty 2018). Advise the patient about importance of taking nutritious food and
encourage him to take more fruits, vegetable and green leafy vegetables (Chan 2015).
Educate the patient about prevention of infection. Watch for breathlessness and shortness of
breath. Educate the patient about the importance of hygiene practises preventing further
infection. Apply universal precautions while caring for the patient. Administer IV fluids as
prescribed. Administer antibiotics as prescribed to prevent the patient from clinical
deterioration (Trautner 2017).
Evaluation
Patient vital signs are normal and the patient’s condition is stable. The patient is aware of the
importance of prevention of further infection and co-operates with the nurse. Have no
symptoms of sever sepsis. The patient is taking high protein and high fibre diet. Have no
signs and symptoms of fluid imbalance. The patient is recovering from the sepsis
Documentation
Documented the vital signs and maintained intake output chart. Documented the non-
pharmacological nursing measures for the treatment of fever. Documented patient education

on the importance of increased fluid intake and nutritious food. Documented IV fluid
administration and antibiotic administration.
Discharge plan
Mr Paul’s knowledge of his condition is limited. The nurse is responsible to make a discharge
plan based on the patient’s knowledge (Hoyer 2019). Primarily, the nurse has to assess the
patient’s knowledge, attitude and belief about the disease condition. Provide basic
information on the signs and symptoms and prevention of sepsis in the simple terms or in a
lay men language. (Trautner 2017). Encourage the patient and his assistant to raise doubts
about home care and clarify the same. Teach the patient on the non-pharmacological
interventions to manage fever.
Encourage the patient to use proper hand washing technique at home. Educate him about the
importance of vaccination. Instruct the patient about the signs and symptoms of infection and
home management. (Trautner 2017). Teach him about the wound dressing in simple terms.
Advise him to do the follow up and explain the benefits of it. Encourage him to continue
nutritious diet and increased fluid intake. Advice the patient to stay away from communicable
infections like common cold, fever, and other respiratory diseases. Provide psychological and
spiritual support (Huang 2016) and provide friendly advice to stop smoking. Provide
information on the ill effects of increased intake of beer.
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