HLTEN606B - Assess clients and manage
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Assess clients and manage client care (HLTEN606B)
Added on 2020-04-21
HLTEN606B - Assess clients and manage
Assess clients and manage client care (HLTEN606B)
Added on 2020-04-21
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Running head: ASSESS CLIENT AND MANAGE PATIENT CAREAssess client and manage patient careName of the student:Name of the University:Author’s note
1ASSESS CLIENT AND MANAGE PATIENT CAREPart 1: Jake Taylor, a 55 year old male roof gutter installer was admitted to the ED viaambulance following fall from the roof (from the height of two meters). His major complain waspain in the abdomen and left shoulder pain. The nursing assessment priority for Jake from mosturgent to least urgent is as follows:Respiratory- The most urgent nursing assessment priority is to conduct respiratory assessment ofpatient to get information related to respiratory rate, auscultation of the lungs and oxygensaturation rate of patient after fall. This is important because high falls often cause soft tissueinjury to lungs and may lead to subdural hematoma (Granhed et al. 2017). Hence, respiratoryassessment may give idea about level of respiratory problem or soft tissue injury in patient afterfall.GIT and metabolic- This assessment is important for patients because Jake has mainlycomplained about abdomen pain since admission to the ED. During this assessment, informationabout past medical history, current lifestyle and medication and nutritional uptake is necessary todetermine the impact of any of these factors in contributing to stomach pain. It may indicateabout intolerance to some food or side effects of medication since Jake is talking manymedications. Onset, intensity and duration of pain will help to determine the correct medicationfor patient too (Macaluso and McNamara 2012). CVS- As the patient sustained fall from high height, checking vital signs like blood pressure andheart rate is necessary to identify symptoms of anxiety and heart rate variability in patients afterfall. It may also give idea about the cardiovascular causes of falls (Palvanen et al. 2014)
2ASSESS CLIENT AND MANAGE PATIENT CARECNS- CNS assessment is important for Jake because fall from high height might have resulted inbrain injury in patient and it may help to predict level of consciousness in patient after fall. Thisassessment may help the nurse to take further action to minimize future fall incidents. Renal- Falls are associated with decrease in renal function in patient and renal assessment mightindicate about fluid balances status and urinary pattern after fall (Gallagher, Rapuri and Smith2007).Skin- Skin assessment is also a vital assessment for patients as he might have sustained severalskin injury and color of skin, temperature and moisture can give idea about any skin infection.Psychological and discharge- Assessment in this area is needed to understand Jake’s emotionand view after fall. This will to gather motivation of patient for recovery and mental capacity tohandle challenges in the treatment process. Part 2:1.The essential nursing assessment for patient with left sided chest pain will be to collectHEART score of patients as it will give data related to history, ECG, age, risk factors andtroponin (Six et al. 2013). The data can help to determine the ischemic nature of chestpain in Jake. The PQRST assessment tool can also help to determine the main factor andseverity of pain patient. As Jake has history of hypertension, the BP assessment of patientwill also be essential to determine the cardiovascular risk status of patient andcardiovascular cause of chest pain (Daskalopoulou et al. 2015). Left sided chest pain is an indication of heart disorder. Blood clot in the lung orpneumothorax can also lead to sharp pain and chances of this are high in Jake due to fall. Te
3ASSESS CLIENT AND MANAGE PATIENT CAREimmediate nursing intervention for left sided chain pain will include immediate vital signassessment of patient and making Jake sit in a semi-Fowler position to review pain. Oxygenationand relevant drugs will also be needed to reduce the intensity of pain (Abbas 2014). 2.The rational for taking HEART score of patient is that this tool considers the riskstratification component responsible for chest pain and so it can help the clinician tomake accurate diagnostic and therapeutic choices for patients like Jake (Six, Backus andKelder 2008). The main advantage of considering semi-fowler’s position for patient with chest pain is thatit facilitates airway management and relieving breathing difficulty in Jake due to chest pain(Godden and CPAN 2016). In addition, oxygen supplementation decreases the pain level if it isischemic in nature (Raut and Maheshwari 2016). 3.Two actual nursing complications due to left sided chest pain include shortness of breathin patient and risk of heart failure in patient. The two potential nursing complicationsevident due to left sided chest pain are development of precarditis and postinfarctionangina in patient. Part 3: Nursing care plan for Jake TaylorActual NursingproblemsInterventionsRationaleEvaluation
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