Medical-Surgical Nursing Notes (Grade A+)

Summary:

Medical-surgical nursing encompasses a wide spectrum of patient care, covering medical conditions and surgical procedures, focusing on assessment, preoperative preparation, and postoperative management. In the assessment phase, comprehensive patient evaluations involve gathering medical history, conducting physical examinations, and analyzing diagnostic results to determine current health status and potential risks. Preoperative care involves verifying consent, confirming fasting, completing essential tests, administering medications, and educating patients about the surgical procedure and associated risks. Subsequently, in the postoperative phase, nurses closely monitor vital signs, assess surgical sites, manage pain, encourage respiratory health, promote mobility, ensure proper hydration and nutrition, administer medications, offer emotional support, prevent complications, and provide patient education to facilitate a successful recovery.

Excerpt:

Medical-Surgical Nursing Notes

Medical-surgical nursing is a broad field that encompasses various aspects of patient care, covering medical conditions, surgical procedures, and nursing interventions. Here’s an overview of some key aspects with explanations and examples:

1. Assessment and Diagnosis:

In-depth patient assessments involve obtaining a thorough medical history, conducting a systematic physical examination, and analyzing diagnostic test results such as blood tests, X-rays, and scans. These assessments aid in identifying patients’ current health status and potential risks.

Assessment:

Assessment is a systematic process of gathering information about a patient’s health status, history, and condition. It involves subjective data (information provided by the patient) and objective data (measurable or observable findings). The assessment aims to comprehensively understand the patient’s health, guiding subsequent care and interventions.

Process of Assessment:
1. Gathering Information: Nurses collect information through interviews, medical records, and observations. This includes the patient’s chief complaint, medical history, family history, allergies, and current medications.
2. Subjective Data: Nurses ask open-ended questions to understand the patient’s perception of their condition. For example, asking about pain’s location, quality, intensity, and duration helps to gather subjective data.
3. Objective Data: Nurses perform a physical examination to gather objective data. This involves using techniques such as inspection, palpation, percussion, and auscultation to assess various body systems.
4. Diagnostic Tests: Nurses may order or facilitate blood tests, X-rays, CT scans, and MRIs to gather additional information about the patient’s condition.