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Nursing Care for People with Complex Conditions

Nursing 1
NURSING CARE FOR PEOPLE WITH COMPLEX CONDITIONS
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Nursing 2
NURSING CARE FOR PEOPLE WITH COMPLEX CONDITIONS
The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) assessment approach
is a systematic process for the onetime assessment and treatment of patients who are injured or
those who are critically ill. It is a process that applies to all clinical emergency settings (Thim et
al., 2012, p. 117). The approach can be used in the street even in the absence of any medical
equipment, on arrival for emergency services, in the intensive care unit, in the emergency room
or general wards in the hospital. The paper, therefore, aims at carrying out the ABCDE
assessment on Janice Kingsley brought in by paramedics and providing a discharge plan for her
six weeks after having hip surgery done.
A-E assessment
At the time of admission, the patient did not have an ECG was done which is necessary.
However, an ECG from a previous admission will be used for her assessment.
Airway
From the available ECG, it is evident that the patient has a quivering or irregular
heartbeat (arrhythmia) or Atrial Fibrillation. Research indicates that various airway difficulties
may indicate the pathogenesis of atrial fibrillation. As Vaughan and Parry (2016) indicate, the
upper airway may narrow and collapse leading to persistent respiratory effort and gradually
swings in intrathoracic pressure that will recur. For this assessment, it will be necessary to check
the patient’s voice and breath sounds. When assessing the patient’s voice, a normal voice
response indicates that the airway is patent (p. 17). However, the airway may be partially or
completely obstructed. Increased breathing effort, a changed voice or noisy breathing including
stridor will be a sign of a partially obstructed airwave. There is lack of respiration in a
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completely obstructed airway despite much effort. Partial of complete airway obstruction will
mainly be caused by a reduced level of consciousness while partial airway obstruction will be
indicated by snoring when the patient is unconscious. An airway obstruction that does not get
treated may result in cardiac arrest, and in this case, the patient is at an increased risk due to the
atrial fibrillation (Powell et al., 2016, p. 53).
As the registered nurse, it will be necessary to use a chin-lift or head tilt maneuver to help
open the patient’s airway. Obstructions like vomit or blood can be easily removed using proper
equipment and suction of the airways. For complete obstruction, if the patient is conscious, it
will be necessary to give five back blows alternated with five abdominal thrusts to the point
where the obstruction is relieved. If the patient is unconscious cardiopulmonary resuscitation
with the assistance of other personnel will be necessary.
Breathing
Assessment for breathing is to determine whether the patient is breathing sufficiently. It
is, therefore, necessary to determine the patient’s respiratory rate, identify the use of auxiliary
respiratory muscles and carry out an inspection of any movements in the patient’s thoracic wall
(Clarke, 2014, p. 53). It is also significant to percuss the patient’s chest for resonance or any
unilateral dullness. It is also important to identify any lateralization of the trachea, cyanosis, and
any neck veins that are distended. Application of a pulse oximeter can be carried out on the
patient, and lung auscultation carried out (Olgers et al., 2017, p.106). The patient was previously
prescribed to use alendronate, which has serious side effects like the swelling of the throat and
trouble breathing. It will be necessary to access for such allergic reactions and address them
immediately. In the case that the patient experiences tension pneumothorax it will be necessary
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to relieve it through the insertion of a cannula where the midclavicular line crosses the second
intercostals space. In case the patient has bronchospasm this should be addressed using
inhalations (Norton, 2017, p. 65). In the event the patient experiences insufficient breathing, it
will be necessary to administer assisted ventilation through the giving of rescue breathes done in
the presence or absence of a barrier device. As a registered nurse, it will also be necessary to use
a bag mask. It will also be necessary to count the patient’s respiratory rate. A normal rate will be
12-20 breaths. A respiratory rate that is high or increasing will be an indication that the patient
will deteriorate suddenly. It is also significant to check for any deformities in the chest including
a raised jugular venous pulse.
Circulation
Assessment of the pulse rate and capillary refill is possible in any setting. An inspection
of the patient’s skin will provide clues on any circulation problems that are present. It will also
be necessary to Identify the color of digits if they are mottled, pink, pale, or blue. Identify if the
patient’s limbs are cool or warm through assessment of limb temperature. It will also be
necessary to measure the patient’s capillary refill time (CRT) (Merriman et al., 2014, p. 121). If
the CRT prolongs, it is a suggestion that poor peripheral perfusion is occurring. Assessment of
the veins for hypovolaemia is also necessary. This may occur if the veins are underfilled or
collapsed. Assessment of equality, presence, regularity, and rate through palpation of the central
and peripheral pulses. In case of a bounding pulse, there is an indication of sepsis, while central
pulses that are barely palpable will indicate poor cardiac output. It is also necessary to measure
the patient’s blood pressure. Arterial vasodilation will be indicated by a blood pressure that is
low and diastolic (Ignacio et al., 2016, p.29). Arterial vasoconstriction will be indicated by a
pulse pressure that is narrowed. It is also necessary to auscultate the heart while trying to identify
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if the pulse rate corresponds to the audible heart rate, if the patient has a pericardial rub or a
murmur, or if her heart sounds are difficult to hear. It is also key to look for indications of
external hemorrhage on the patient from drains or wound. It will also be necessary to identify
evidence of hemorrhage that is concealed including into gut, intra-peritoneal and much more.
Disability
If the patient is unconscious, the main courses might be a recent administration of
analgesic drugs or sedatives, hypercapnia, profound hypoxia or cerebral hypoperfusion. If will be
necessary to first review, identify and treat the ABCs (Moruzzi and McLeod, 2017, p. 128). It
will also be significant to treat or exclude hypotension or hypoxia in the patient. Given the recent
prescriptions, the patient has it would be safe to check for any drug-induced causes of depressed
consciousness. Administration of an antagonistic like opioid toxicity or naloxone can be done
where necessary. The patient’s pupils also need to be examined especially their reaction to light,
their size, and equality. The AVPU method is appropriate for carrying out a rapid initial
assessment of the patient’s level of consciousness. Is the patient alert, does she respond to vocal
stimuli, does she respond to stimuli that are painful, is she unresponsive to all stimuli.
Measurement of the patient’s blood glucose is also necessary to help rule out hypoglycemia. In
case the patient is unconscious, it is significant that she is nursed in the lateral position especially
if her airway is not protected.
Exposure
A thorough physical examination of the patient’s body should be carried out while the
patient’s clothing is removed. It is only after the patient’s dignity is considered. It is important to
check for signs of trauma, skin reactions especially rashes, marks of needles, signs of trauma, or
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bleeding (Dunkley and McLeod, 2015, p. 32). In the absence of a thermometer, the patient’s
body temperature can be felt and determined through feeling the skin or otherwise using the
thermometer. It will also be important to take a full history either from the patient, other
members of staff, and any relative or friends if they are available.
Discharge plan
It is necessary for the patient to take part in rehabilitation to ensure that her strength and
mobility is increased. After six weeks of treatment and care in the hospital, the patient can be
viewed as medically stable and therefore the primary goals for treatment at the point of her
discharge focus on rehabilitation. These goals include;
Optimization of nutrition
Poor nutrition is often associated the increase in mortality and morbidity especially for
patients in the hip fracture population (Inoue et al., 2017, p. 1322). It will be necessary for the
patient to be on protein/vitamin supplements or nasogastric feeding (Nordstrom et al., 2016, p
91). It will help in reduction of major complications experienced by such a patient, and it will
ensure that she has reduced hospital length of stay. The patient will need to continue with
nandrolone decanoate plus oral protein supplementation, which is essential in increasing her
levels of albumin and helping her maintain a lean body mass unlike when she engages in oral
protein supplementation only.
Multidisciplinary care
This type of care involves management that is team based. It involves various
professionals including a medical practitioner, a physical therapists, the registered nurse and
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other healthcare professionals. These professionals come together to plan treatment that will
meet the complex care needs of the patient. It will, therefore, be necessary to work in
conjunction with other medical practitioners in the institution to develop a holistic care plan for
the patient even after she leaves the hospital (Prestmo et al., 2015, p. 1630). The plan will
involve guidance on how she needs to use the medications prescribed, how she should care for
herself while out of the hospital to make sure she does not come back and identification of the
best support care she can get from outside hospital that will help attain full recovery. The plan
will also incorporate her nutritional needs and any guidance for physiotherapy or exercises she
can engage in.
Skilled nursing facility
The patient has previously been diagnosed with hypertension, which means that recovery
after surgery for her will need specialized care. Therefore, a skilled nursing facility will be an
appropriate institution for Janice to get care after surgery (Flodin et al., 2016, p. 148). Patients
who suffer from conditions like hypertension or diabetes will take longer to recover from surgery
than one with no medical problems. It is, therefore, necessary to identify a skilled nursing facility
in the community for her where she can engage in specialized one-hour care and rehabilitation
each day after discharge to ensure that she makes a full recovery. Once a good facility is
identified, a social worker will come in to assist Janice in making the transition.
Post the operation the patient needs to become mobile. The patient is introduced to
weight-bearing exercises as dictated by occupational and physical therapy. It will also be
necessary for the patient to be on low-molecular-weight heparin. The patient is also at high risk
of thromboembolic events in her population, which necessitates that she is placed on intermittent
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pneumatic compression devices and continues on clopidogrel. Further consultation is also
important concerning her nutrition considering that she might have been admitted with low
levels of albumin. A moderate-level recommendation would be to start the patient on nutritional
supplements after the surgery to help improve caloric intake and also improve her protein levels.
It is also important to assess for her levels of vitamin D and in the instance that her levels are low
she will need to be initiated on vitamin D and calcium supplementation (Schiller et al., 2015, p.
57).
A regional nerve block that is long-acting necessitates effective management of pain after
surgery (Tian et al., 2016, p. 679). A strong grade recommendation is the use of a multimodal
pain regimen, which may include tramadol, perioperative celecoxib, acetaminophen, and oral
narcotics that are long-acting. These will help in minimizing narcotic pains, which in turn will
also help avoid the development of delirium in the patient. It is also important that the patient’s
hemoglobin level is assessed postoperatively and a check on her blood pressure considering that
she was previously treated for and has hypertension. It is often recommended that the patient
undergoes a blood transfusion of no higher than 8.1g/dL after operation (Grigoryan et al., 2014,
p. 49). However, assessment of the necessity for the transfusion needs to be done considering the
risks involved. It is significant to analyze the presence of any lightheadedness or tachycardia to
make sure that sufficient hydration is recommended for the patient in case the two are present.
Her hospital stay progressed well, and therefore an interdisciplinary care program needs
to be implemented postoperatively including rehabilitation, post-hospital services, and effective
discharge planning. Considering that the patient is in her old age and is at the risk of dementia, it
is necessary to access for this and ensure that the interdisciplinary care approach is implemented
to help improve her functional outcomes (van Wyk et al., 2014, p. 40). The interdisciplinary
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approach will help the patient in her effective transition from the inpatient care to sub-acute care
and rehabilitation and eventually back into her home where she can experience home care.
Prescription of continued calcium and vitamin D supplementation is necessary, and it is
necessary for the patient to get an outpatient osteoporosis evaluation considering that she is at an
increased risk of fragility fractures (Roberts et al., 2015, p. 135).
Unless there is any contradiction, it will be important for the patient to be on
bisphosphonates. It is because a previous hip fracture puts the patient at increased risk of
another. Therefore, regardless of the patient’s bone mineral density results, it will be necessary to
place her on bisphosphonate therapy to reduce her risk of another fracture (Folbert et al., 2017, p.
272). It will work well with a combination of the calcium and vitamin D recommended earlier.
Any risks associated with the use of bisphosphonate therapy will be experienced after five years
of engagement. A fall prevention assessment will be effective and beneficial for the patient.
Therefore assessing the removal of environmental hazards in her home, conducting a review of
her medication and assessment of her gait, balance and muscle strength will be highly helpful for
Janice. Location for the patient’s rehabilitation including outpatient, a skilled nursing facility or
home will highly depend on her motivation and capabilities. If the patient goes for outpatient
care, her functional status will be significantly improved (Rath and Dey, 2017, p. 190). If the
patient is still on warfarin it will be significant that she stops taking the medication to ensure that
she is not at a risk of bleeding. She will also need to stay away from driving considering that she
has just had a surgery done on her hip and that metoprolol, which she had been previously
prescribed may make her dizzy or cause memory problems.
In conclusion, the A-E assessment of the patient addressed the priorities for nursing care
that was necessary for the patient. The assessment considered the medical history of the patient
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drug reports, prescriptions and an ECG carried out on the patient on a previous visit. It was
necessary to consider any risks the patient was vulnerable to even while carrying out the
assessment. A thorough assessment would ensure that the patient gets the best care the facility
could provide. The discharge plan, on the other hand, focused on providing options and
recommendations for the patient’s care after an operation on the hip. The plan considered which
type of care would be necessary to ensure full recovery while considering the patient’s age,
previous medical history, and other environmental factors.
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References
Clarke, C., 2014. Promoting the 6Cs of nursing in patient assessment. Nursing Standard, 28(44),
pp.52-59.
Dunkley, S. and McLeod, A., 2015. Neutropenic sepsis: assessment, pathophysiology and
nursing care. British Journal of Neuroscience Nursing, 11(2).
Flodin, L., Laurin, A., Lökk, J., Cederholm, T. and Hedström, M., 2016. Increased 1-year
survival and discharge to independent living in overweight hip fracture patients. Acta
orthopaedica, 87(2), pp.146-151.
Folbert, E.C., Hegeman, J.H., Vermeer, M., Regtuijt, E.M., van der Velde, D., Ten Duis, H.J.
and Slaets, J.P., 2017. Improved 1-year mortality in elderly patients with a hip fracture
following integrated orthogeriatric treatment. Osteoporosis International, 28(1), pp.269-
277.
Grigoryan, K.V., Javedan, H. and Rudolph, J.L., 2014. Ortho-geriatric care models and outcomes
in hip fracture patients: a systematic review and meta-analysis. Journal of orthopaedic
trauma, 28(3), p.e49.
Ignacio, J., Dolmans, D., Scherpbier, A., Rethans, J.J., Lopez, V. and Liaw, S.Y., 2016.
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clinical performance and reduce stress: A mixed methods study. Nurse education today,
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Inoue, T., Misu, S., Tanaka, T., Sakamoto, H., Iwata, K., Chuman, Y. and Ono, R., 2017. Pre-
fracture nutritional status is predictive of functional status at discharge during the acute
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phase with hip fracture patients: a multicenter prospective cohort study. Clinical
Nutrition, 36(5), pp.1320-1325.
Merriman, C.D., Stayt, L.C. and Ricketts, B., 2014. Comparing the effectiveness of clinical
simulation versus didactic methods to teach undergraduate adult nursing students to
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Moruzzi, M. and McLeod, A., 2017. Hypovolaemic shock: assessment, pathophysiology and
nursing care. British Journal of Neuroscience Nursing, 13(3), pp.126-132.
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