Protocols for the Most Common Diseases in Primary Healthcare Facilities

·      Patient Assessment:

-       Triage and prioritize patients in accordance with the Patient Triage and Prioritization Policy (Start Triage or Australian Triage).

-       Perform a physical assessment of the different body systems according to the patient's presenting complaint.

-       Conduct a psychosocial assessment and evaluate the educational needs of the patient and family.

-       Assess pain and notify the physician if the pain score is 3 or higher.

-       Perform a fall-risk assessment.

-       Conduct psychological, spiritual, and nutritional assessments.

-       Perform a geriatric assessment if the patient is 65 years of age or older.

·      Nursing Procedures:

-       Measure vital signs (blood pressure, blood glucose, pulse, respiratory rate, temperature, and oxygen saturation) and notify the physician of the results in accordance with the Critical Results Reporting Policy, when applicable.

-       Measure height and weight and calculate body mass index (weight in kilograms / height in meters squared).

-       Document the case on the Emergency Department Record form.

-       Develop and implement a nursing care plan.

-       Administer treatment as prescribed by the physician.

-       Provide the patient with health education appropriate to the condition.

-       Complete electronic documentation of all nursing forms in the system.

-       Open and complete the Emergency Department Record.

-       Document the patient in the emergency log upon admission to and discharge from the Emergency Department.

·      Health Education:

-       Explain the concept of hypertension to the patient:

Definition of Blood Pressure:

Blood pressure is the force generated within the large blood vessels (arteries) when the heart pumps blood so that it circulates throughout the body.

Narrowing of the arteries causes blood pressure to rise.

•       When the heart muscle contracts to propel oxygenated blood throughout the body, the pressure generated by the heart reaches its highest level; this is known as systolic blood pressure.

•       When the heart muscle relaxes before the next contraction, this is known as diastolic blood pressure.

•       Hypertension is the level of blood pressure at which treatment with antihypertensive medication provides more benefit than harm.

•       Blood pressure is considered elevated when it remains above the normal range during physical and psychological rest.

•       High blood pressure is called the “silent killer” because it usually causes no symptoms until an advanced stage of the disease. 

Prehypertension is the stage in which the blood pressure reading is slightly higher than usual. If your reading is 139/89 mmHg, you are in the prehypertension stage. The condition may worsen in the future and become chronic or long-term; therefore, it is important to consult a physician about how to maintain a normal blood pressure level and prevent the disease.

Normal adult blood pressure: 120/80 mmHg, with a variation of ±20/15 mmHg.

-       Educate the patient about the prevention of hypertension:

Adopt a healthier lifestyle:

1- Lose excess weight.

2- Exercise regularly (walking).

5- Abstain from alcohol.

6- Stop smoking.

7- Take medications regularly as prescribed.

8- Follow a healthy diet:

-       Discontinue unhealthy eating habits.

-       Organize meals and eating times.

-       Avoid excessive intake of sugars, fats, and salt.

-       Increase the intake of potassium-rich foods, such as bananas, oranges, and dates. However, patients with renal failure must avoid foods high in potassium and phosphorus.

-       Eat fresh fruit and vegetables whenever possible.

- Reduce dietary salt intake.

-Avoid convenience foods, fast food, canned foods, and preserved foods.

- Avoid pickles and high-salt foods, such as salted fish and salted nuts,

ketchup, potato chips, etc.

- Maintain a healthy weight appropriate for age and height, and lose excess weight by following a balanced diet.

- The diet should contain as little animal fat and salt as possible while remaining rich in all essential nutrients, including potassium, magnesium, and calcium.

- Increase the intake of fruit and vegetables.

- Avoid fats, particularly saturated fats of animal origin.

- Increase the intake of potassium-rich foods. It is therefore recommended to eat more fruit and vegetables because they are rich in potassium (4-5 servings daily), such as bananas, oranges, dark leafy vegetables, legumes, dairy products, and meat.

- Eat “oily” fish:

Eating fish, particularly oily fish such as mackerel, salmon, and tuna, helps lower blood pressure and reduces blood viscosity and the tendency to clot because these fish contain unsaturated fatty acids known as omega-3. Eating fish at least once a week is therefore recommended. 

- Calcium:

Maintaining an adequate daily dietary intake of calcium helps prevent hypertension. Dietary calcium deficiency has been associated with elevated blood pressure.

Adults require 800-1,200 mg of calcium per day.

Low-fat milk and dairy products are recommended.

- Fiber: Eat fiber-rich foods (fruit and vegetables) every day.

- Daily sodium intake should not exceed 2.4 g.

- Daily fat intake should not exceed 30% of the total daily calories appropriate for the body, to prevent elevated blood lipids and atherosclerosis. Therefore, reduce overall fat intake.

Reduce saturated fats, such as butter, ghee, cream, etc., to 10% or less of total fat intake because they directly raise blood cholesterol, thereby contributing to atherosclerosis and hypertension.

- Avoid hydrogenated oils (commercial shortening).

9- Reduce psychological stress.

-       Explain the factors that contribute to hypertension:

Modifiable risk factors:

Unhealthy diet:

·      A diet high in sodium (salt) and low in potassium increases the risk of developing hypertension.

·      Most of the sodium we consume comes from fast food and processed and canned foods.

·      Inadequate potassium intake can also raise blood pressure. Potassium is found in foods such as bananas, potatoes, legumes, and yogurt.

Physical inactivity:

·      Insufficient physical activity contributes to weight gain, which in turn can lead to elevated blood pressure.

Obesity:

·      Obesity is an excessive proportion of body fat. It can cause hypertension and is assessed by calculating body mass index. It may also lead to heart disease and diabetes mellitus.

Smoking:

·      Smoking in all forms increases the risk of hypertension.

·      Smoking can damage the heart and blood vessels.

·      Nicotine raises blood pressure, while carbon monoxide inhaled during smoking reduces the amount of oxygen carried by the blood.

Excessive alcohol consumption:

·      Excessive alcohol consumption can raise blood pressure.

Non-modifiable risk factors:

·      Genetic factors and family history: certain traits are passed from one generation to the next through genes; this is known as heredity.

·      Other factors include:

- Age: Blood pressure tends to rise with age, and the risk of hypertension increases as a person gets older.

-       Explain the complications of hypertension so that the patient can help prevent them:

- Angina pectoris.

  - Myocardial infarction (heart attack).

- Cardiac arrest and shortness of breath.

- Irregular heartbeat.

- Stroke.

- Cognitive impairment.

- Peripheral arterial disease (damage to the major blood vessels in the legs).

- Kidney damage.

- Eye damage (visual impairment caused by bleeding from retinal blood vessels).

-       Explain the effect of persistent hypertension on the heart:

When hypertension persists for a long period, the heart muscle becomes thicker because it must work harder to overcome the increased pressure. The thickened heart muscle also becomes stiffer and functions less efficiently than a normal heart muscle. 

-       Educate the patient about first aid for epistaxis (nosebleed):

·      Sit upright and lean the head forward toward the chest, and avoid swallowing the blood.

·      Pinch both nostrils between the thumb and index finger just above the bleeding site for 10 minutes. Keep the mouth open for breathing while applying pressure. An ice pack may be placed over the bridge of the nose.

·      Have the patient spit out any blood that has accumulated in the throat.

·      After the bleeding stops, explain the importance of avoiding forceful breathing through the nose.

·      If the bleeding does not stop within 30 minutes, transfer the patient to a medical facility.

References:

Arslan, G., & Mollaoğlu, M. (2021). Evaluating sleep quality in patients with hypertension. Primary Health Care, 31(3).

Oliveros, E., Patel, H., Kyung, S., Fugar, S., Goldberg, A., Madan, N., & Williams, K. A. (2020). Hypertension in older adults: Assessment, management, and challenges. Clinical cardiology, 43(2), 99-1 

2- Nursing care for a patient experiencing an asthma exacerbation:

1- Patient Assessment:

-       Perform a physical assessment of the different body systems, with particular emphasis on the respiratory system, according to the patient's presenting complaint.

-       Review the medication history for drugs used to treat nasal or chest allergies.

-       Assess pain and notify the physician if the pain score is 3 or higher.

-       Perform an age-appropriate fall-risk assessment for adults or children.

-       Conduct psychological, spiritual, and nutritional assessments.

-       Perform a geriatric assessment if the patient is 65 years of age or older, a pregnancy assessment for pregnant women, and a pediatric assessment for children under 5 years of age.

2- Nursing Procedures:

-       Triage and classify cases to determine the priority of intervention.

-       Measure vital signs (blood pressure, blood glucose, pulse, respiratory rate, temperature, and oxygen saturation).

-       Measure height and weight and calculate body mass index.

-       Develop and implement a nursing care plan.

-       Administer treatment as prescribed by the physician.

-       Provide the patient with health education appropriate to the condition.

-       Complete electronic documentation of all nursing forms in the system.

-       Open and complete the Emergency Department Record.

-       Document the patient in the emergency log upon admission to and discharge from the Emergency Department.

3- Health Education:

Lifestyle and home care (avoid triggers by doing the following):

1-   Use air conditioning to reduce the amount of airborne tree pollen entering the home. If air conditioning is unavailable, keep windows closed during pollen season.

2-   Reduce household dust that may worsen nighttime symptoms by modifying bedroom furnishings. For example, cover pillows, mattresses, and bed frames with dust-proof covers; avoid down-filled pillows and blankets; remove carpets throughout the home and replace them with wood or linoleum flooring; and use washable curtains and blinds.

3-   Maintain an optimal humidity level.

4-   Prevent mold spores: Clean damp areas in the bathroom, kitchen, and throughout the home to prevent mold growth. Remove decaying leaves or damp firewood from the yard.

5-   Reduce exposure to pet dander: If you are allergic to dander, avoid pets with fur or feathers.

6-   Clean regularly: Clean the home at least once a week. If cleaning is likely to stir up dust, wear a mask or ask someone else to clean. Wash bedding regularly.

7-   Cover your nose and mouth when the weather is cold outside.

Lifestyle and home care (exercise regularly).

Having asthma does not mean that you must be less active. Appropriate treatment can prevent asthma attacks and control symptoms during physical activity.

Regular exercise can strengthen the heart and lungs and help relieve asthma symptoms. When exercising in cold weather, wear a face covering to warm the air you breathe.

Lifestyle and home care (maintain a healthy weight).

Excess weight can worsen asthma symptoms and increase the risk of other health problems.

Control heartburn and gastroesophageal reflux disease (GERD).

Acid reflux, which causes heartburn, may damage the airways in the lungs and worsen asthma symptoms.

If you experience frequent heartburn, discuss treatment options with your physician.

Coping and Support:

1-   Pace yourself: Take breaks between tasks and avoid activities that worsen your symptoms.

2-   Prepare a daily task list. This may help prevent feelings of stress. Reward yourself for achieving simple goals.

3-   Talk with other people who have the same condition so you know that you are not alone.

4-   If your child has asthma, be encouraging. Focus on what your child can do rather than what the child cannot do. Ask teachers to help your child manage asthma.

Take medications regularly.

Long-term asthma-control medications are taken daily. They provide day-to-day control and reduce the likelihood of an asthma attack. These medications include inhaled corticosteroids and other agents.

References:

·      Asthma. National Heart ,lung ,and blood Instituto- https:// www. Nih. Gov/ health: topics/ asthma .Accessed march 25-2020

·      MacGeorge, C. A., King, K., Andrews, A. L., Sterba, K., Johnson, E., Brinton, D. L., ... & Ford, D. (2021). School nurse perception of asthma care in school-based telehealth. Journal of Asthma, 1-8.‏

·      Rukahu, F. (2021). Nurses' role and their knowledge in caring for severe asthma patients.‏

·      Rupasinghe, M., Reath, J., Cvetkovski, B., Smith, S., Bosnic-Anticevich, S., Kritikos, V., & Abbott, P. (2021). Have we got the right focus in asthma care in general practice? A qualitative study. Australian Journal of General Practice, 50(6), 410-415 

Nursing care for a patient with renal colic:

1- Patient Assessment:

-       Perform a physical assessment of the different body systems, with particular emphasis on the urinary system, according to the patient's presenting complaint.

-       Review the medication history.

-       Assess pain and notify the physician if the pain score is 3 or higher. Reassess pain after treatment as prescribed by the physician.

-       Perform an age-appropriate fall-risk assessment for adults or children.

-       Conduct psychological, spiritual, and nutritional assessments.

-       Perform a geriatric assessment if the patient is 65 years of age or older, a pregnancy assessment for pregnant women, and a pediatric assessment for children under 5 years of age.

2- Nursing Procedures:

-       Measure vital signs (blood pressure, blood glucose, pulse, respiratory rate, and temperature).

-       Measure height and weight and calculate body mass index.

-       Develop and implement a nursing care plan.

-       Administer treatment as prescribed by the physician and reassess pain.

-       Provide the patient with health education appropriate to the condition.

-       Complete electronic documentation of all nursing forms in the system.

3- Health Education: 

Patient education: Definition of renal colic:

Renal colic is a disorder characterized by severe pain in the kidneys and urinary tract, caused by a stone in the kidney, renal pelvis, or ureter.

Kidney stones form when urine becomes highly concentrated with various salts, causing them to crystallize and form stones that may obstruct or infect the urinary tract.

In renal colic, stones begin as small crystals deposited in the kidneys. These would normally pass from the body without harm; however, they may grow into stones that cause severe pain and other symptoms.

Patient education: Symptoms of renal colic:

Symptoms of renal colic include:

·        Sudden, severe pain in the lower back that may radiate to other areas along either side of the back.

·        Pain during urination.

·        Fever when infection is present.

·        Shivering or chills.

·        Foul-smelling urine.

·        A persistent urge to urinate.

·        Nausea and vomiting.

·        Blood in the urine.

Patient education: Causes and risk factors for renal colic:

Renal colic is caused by stones in the urinary tract, most commonly in the ureter. Stones may develop as a result of several risk factors, including:

·        Excess calcium in the urine.

·        Gastrointestinal disorders.

·        Gout.

·        Certain medications.

·        Previous gastrointestinal surgery.

·        Family history of urinary stones.

Patient education: Complications of renal colic:

Renal colic is not a disease in itself; it is a symptom of urinary tract stones. Therefore, it does not cause specific complications by itself.

If kidney stones are left untreated, complications may occur, including urinary tract infection and kidney damage.

Patient education: Prevention of renal colic:

Renal colic can be prevented by avoiding factors that may lead to kidney-stone formation, as follows:

·        Increase fluid intake and reduce dietary sodium.

·        Take diuretics, as prescribed by the physician, if the person is at risk of developing kidney stones.

·        Follow a healthy, low-fat diet containing adequate amounts of vegetables, fruit, and grains.

References:

·      Moussa, M., Papatsoris, A. G., & Abou Chakra, M. (2021). Intradermal sterile water injection versus diclofenac sodium in acute renal colic pain: a randomized controlled trial. The American Journal of Emergency Medicine, 44, 395-400

·      Sen, V., Ongun, S., Sahin, M. O., Irer, B., Kizer, O., Dogan, B., & Yildiz, G. (2021). The use of computed tomography as the first imaging modality in patients with renal colic and microscopic haematuria. International Journal of Clinical Practice, 75(3), e13826. 

Vomiting

Nursing care for a patient experiencing vomiting:

·      Patient Assessment:

-       Perform a physical assessment of the different body systems according to the patient's presenting complaint, with particular emphasis on the gastrointestinal system.

-       Perform a fall-risk assessment.

-       Conduct psychological, spiritual, and nutritional assessments.

·      Nursing Procedures:

-       Measure vital signs (blood pressure, blood glucose, pulse, respiratory rate, and temperature) and notify the physician of the results in accordance with the Critical Results Reporting Policy.

-       Develop and implement a nursing care plan.

-       Administer treatment as prescribed by the physician.

-       Complete electronic documentation of all nursing forms in the system.

·      Health Education:

Pregnant women experiencing morning nausea and vomiting may eat dry baked foods, such as sesame breadsticks or rusks, or have a light protein snack before bedtime, such as cheese or lean meat. They should consult the physician about antiemetic medications to select one that is appropriate during pregnancy.

Vomiting associated with cancer therapy may be treated with specific medications compatible with the treatment regimen, as prescribed by the physician.

If vomiting accompanied by diarrhea persists for more than 24 hours, oral rehydration solution should be used, as prescribed by the physician, to protect the patient from dehydration.

Eat small meals throughout the day instead of three large meals.

Avoid solid foods that are difficult to digest.

Drink fluids gradually, beginning with warm fluids.

Rest after eating, keep the head elevated, and avoid lying down immediately after meals.

Avoid acidic juices, such as orange, grapefruit, and lemon juice, because they increase nausea and the urge to vomit.

Do not exercise or engage in vigorous movement after eating, as this may irritate the stomach and increase the urge to vomit.

People prone to motion sickness may experience increased nausea, dizziness, and the urge to vomit when sitting by a window and watching the rapid movement outside. Interior seats are therefore preferable to window seats 

References:

·      Byrne, K., Renton, B., & Renton, B. (2021). An unusual cause of persistent vomiting. The multispecialty review journal for hospital doctors, 203, 202.‏

·      Blackett, D. L. (2021). Perceptions of Using Complementary Alternative Medicine during Pregnancy for Nausea and Vomiting (Doctoral dissertation, Walden University).

·      Reeves, P. T., Kovacic, K., Rogers, P., Sanghavi, R., Levinthal, D., Echelmeyer, S., & Li, B. U. K. (2021). Development and Assessment of a Low Literacy, Pictographic Cyclic Vomiting Syndrome Action Plan. The Journal of Pediatrics.‏ 

Patient Assessment:

-       Perform a physical assessment of the different body systems according to the patient's presenting complaint.

-       Assess pain and notify the physician if the pain score is 3 or higher.

-       Perform a fall-risk assessment.

-       Conduct psychological, spiritual, and nutritional assessments.

-       Perform a geriatric assessment if the patient is 65 years of age or older.

1-  Nursing Procedures:

-       Measure vital signs (blood pressure, blood glucose, pulse, respiratory rate, and temperature).

-       Measure the blood glucose level and notify the physician of the result.

-       Measure height and weight and calculate body mass index.

-       Develop and implement a nursing care plan.

-       Complete electronic documentation of all nursing forms in the system.

Symptoms of diabetic ketoacidotic coma:

1.   Increased urination.

2.   Severe hunger and thirst.

3.   Blood pressure disturbance.

4.   Constipation.

5.   Difficulty breathing.

6.   Tendency to vomit and abdominal pain.

7.   Dry, flushed skin.

8.   Dizziness and anxiety.

9.   A fruity, apple-like odor on the breath.

Symptoms of hypoglycemic coma:

1.   Disorientation and poor concentration.

2.   Occasional seizures.

3.   Loss of consciousness or excessive hand movements.

4.   Rapid, fluttering heartbeat.

5.   Hand tremors.

6.   Facial pallor with sweating. 

Procedures:

Nursing procedures for diabetic ketoacidotic coma: 

1.   Monitor and document vital signs and obtain a random blood glucose measurement.

2.   Collect urine and blood specimens for the tests available at the unit or center, and test the patient's urine for ketones as directed by the physician. The patient's breath is commonly characterized by an acetone odor.

3.   Administer insulin according to the blood glucose result and the physician's orders.

4.   Administer intravenous fluids if dehydration accompanies the ketoacidotic coma, as prescribed by the physician.

5.   Monitor the patient's level of consciousness and observe for any deterioration.

6.   Educate the patient's family about diet, exercise, adherence to treatment, the importance of follow-up, personal hygiene and infection prevention, urine testing for glucose and ketones, and self-administration of insulin when the patient is able to do so. 

Nursing procedures for hypoglycemic coma: 

1- Monitor and document vital signs and obtain a random blood glucose measurement.

2- Insert a peripheral intravenous cannula promptly.

3- Administer 25% glucose solution, as available at the center or unit and as prescribed by the physician.

4- Measure random blood glucose every 15 minutes.

5- The patient usually improves within 30 minutes. If there is no improvement, transfer the patient to the nearest hospital. 

Health education for patients with diabetes: 

This is a nursing intervention that must be provided to the patient or family to prevent complications.

Daily foot care:

·      Wash the feet with a good-quality soap and lukewarm water, then dry thoroughly, especially between the toes, by patting rather than rubbing vigorously to protect skin integrity.

·      Apply cream or edible oil to keep the feet soft and reduce friction. Massage with alcohol once weekly, moving from the toes upward. If varicose veins are present, massage the feet very gently and do not massage the legs.

Daily nail care:

·      Soak the nails for 30 minutes each day in lukewarm water containing one teaspoon of dissolved borax. Pat dry, then massage the surrounding area with oil or nourishing cream to strengthen the nails and prevent cracking.

·      Cut the nails straight across. Do not cut them too short into the soft tissue, and do not cut down the sides.

·      Choose comfortable, low-heeled shoes that do not compress the toes. New shoes should be worn for only 30 minutes on the first day and one hour on the second day.

To prevent circulatory problems:

·      Advise the patient to stop smoking to prevent constriction of the blood vessels.

·      Keep the feet warm.

·      Perform leg exercises and avoid wearing anything that constricts the legs, to improve blood circulation.

·      Do not take any medication or place the feet near hot water without consulting the treating physician.

·      Change socks at least once daily.

·      If any wound occurs, cover it immediately with sterile or clean gauze and consult the physician promptly.

·      Do not wear shoes when a wound is present on either foot.

·      Notify the physician if redness, blisters, pain, or swelling appears, to prevent infection that could lead to gangrene.

Perineal care:

·       Wash the area thoroughly after urination or defecation and dry it well with a soft cotton towel.

·      Change underwear daily and whenever needed. Cotton underwear is recommended so that it can be washed in hot water and dried in sunlight.

·      Observe for any sores or skin folds and report them immediately to the treating physician. 

Eye-care measures that reduce risk:

·      Have a complete eye examination every year.

·      Notify the physician if blurred vision, a dark spot, inability to see objects clearly, or a sensation of pressure or pain in the eye occurs.

·      Difficulty seeing in dim light.

·      Have intraocular pressure measured periodically.

Dental care:

·      High blood glucose increases the risk of dental and gum problems. Good daily care at home and regular dental visits help prevent these problems.

·      Brush the teeth daily; this is the best way to keep the teeth and gums healthy.

·      Visit the dentist every five months.

·      Inform the dentist that you have diabetes. 

Ramadan fasting and diabetes: 

·      For patients with diabetes, fasting may be beneficial in the management of type 2 diabetes because it provides an opportunity to follow the diet prescribed by the treating physician. This may reduce body weight and may lead to remission in mild cases managed by diet alone.

·      In cases treated with glucose-lowering tablets, blood glucose and body weight may decrease, thereby improving the body's response to glucose-lowering medication.

Daily instructions for patients with diabetes:

·      Take diabetes tablets or insulin at the prescribed dose and exactly as directed by the physician.

·      Notify the physician when feeling unwell or when an infection is suspected.

·      Check blood glucose approximately every 24 hours.

·      Test urine for ketones if the blood glucose level exceeds 240 mg/dL.

·      If the patient has an upset stomach, take fluids in small amounts to prevent vomiting.

·      Carry a card stating that the person has diabetes, the type and dose of treatment, the times at which it is taken, and the physician who

·      supervises the treatment or the hospital attended for care. 

References:

Munawar, K., & Choudhry, F. R. (2021):- Exploring stress coping strategies of frontline emergency health workers dealing Covid-19 in Pakistan: A qualitative inquiry. American journal of infection control, 49(3), 286-292 

Laermans, J., Borra, V., Van Remoortel, H., Vande Veegaete, A., De Buck, E., & Van De Kerckhove, P. (2018): First aid guideline for caregivers. Tijdschrift voor Geneeskunde, 74(4), 233-239.‏ 

Mazurek, M. O., Sadikova, E., Cheak-Zamora, N., Hardin, A., Huerta, I., Sohl, K., & Malow, B. A. (2021): They deserve the “same level of care that any other person deserves”: Caregiver perspectives on healthcare for adults on the autism spectrum. Research in Autism Spectrum Disorders, 89, 101862.