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