Nursing Assessment of Mr. William: Case Study and Nursing Problems

This article presents a nursing assessment of Mr. William, a 48-year-old man who sustained injuries from a fall. The assessment reveals his injuries, pain level, and abnormal vital signs. The article also identifies five nursing problems, including pain, hypertension, stress and anxiety, bruising, and electrolyte imbalance. The assessment plan for each problem is discussed to improve the quality of William's care.

Running Head: Nursing Assessment, Case Study of Mr. William 1
Nursing Assessment, Case Study of Mr. William
Student Name
Institution
Date

Nursing Assessment, Case Study of Mr. William 2
GENERAL APPEARANCE
Mr. Williams is a 48- year- old man. He was admitted following a fall from a
height of approximately 2 meters at his workplace. As a result of the fall, he
sustained some injuries such as fractured ribs on his right side, significant bruising
on his upper thigh and a dislocation on his right shoulder. Additionally, he also
sustained some damage on his protective headwear although no loss of
consciousness was reported. Williams’s rate of ambulation has been minimal with
a bit of morphine to help manage the pain.
DATA/ CUES / Signs and Symptoms. Indicate Normal
(N) or Abnormal (A)
Neurological CNS Subjective: conscious (N), able to make movements (N), hearing well
(N), no coordination of movement (A).
Objective: Pain 4/10 (A), 3 fractured ribs (A)
CVS Subjective: conscious (N), no reports of cardiac output (N)
Objective: HR irregular (A), HR- 105 (A), BP- 150/80 (A)
Respiratory Subjective: No history of cardiac diseases (N), oxygen saturation 94%
(N), No visible airway obstruction (N)
Objective:RR-25bpm (A)

Nursing Assessment, Case Study of Mr. William 3
Genitourinary
Renal
Subjective: Has been passing urine normally (N)
Objective:
Musculoskeletal
Subjective: Normal movement of muscles (N)
Objective:
Gastrointestinal
GIT
Subjective:
Objective:
Integument Subjective:
Objective:
Endocrine/
Metabolic
Subjective:
Objective:
Psychosocial/other
Subjective: Talks in a friendly manner (N)
Objective:

Nursing Assessment, Case Study of Mr. William 4
Assessments
SYSTEM ABNORMAL NORMAL
Neurological and sensory  3 fractured ribs  conscious
System difficulty to move  Able to make movements
 Pain (4/10 level)  No symptoms of seizures
slightly high  Hearing well
 No coordination of  Able to adjust herself in bed
Movement  Doesn’t have slurred speech
 Limited ambulation
Mental health  Restlessness  Appears to be conscious
Cardiovascular system  HR- irregular  Conscious and does not report
 HR-105 Any breathlessness or low
Cardiac output
 BP-150/80
Respiratory system  RR-25bpm  No history of cardiac diseases
 Oxygen saturation 94%
 No visible airway obstruction
Renal/bladder  Has been passing urine normally
Skin, hair, nails  Pale Dry skin and  Greying hair
Temp-37.8
Musculoskeletal  Full body movement
 Correct posture
Psychosocial  Friendly to talk

Nursing Assessment, Case Study of Mr. William 5
3
PART B
There are 5 nursing problems which have been identified in the case of Mr. William as shown in the table
below
S.N Problem Support data
1 Pain The assessment has revealed that pain level of Mr. William is high (4/10)
as per the pain scale
2 Hypertension The blood pressure of Mr. William is very high (150/80) and he is always
sweaty
3 Stress and anxiety As a result of the fractured and dislocation of ribs on his right side, Mr.
William can hardly make any movements. He is facing mobility issues
4 Bruising The skin of Mr. William has been observed to be pale and a significant
bruising has also been observed on his right thigh
5 Electrolyte
Imbalance
Both the heart and respiration rates of Mr. William are abnormal. His
heartbeat is irregular
In order to improve the quality of William’s care, a detailed and systematic assessment of his nursing
problems will be carried out as indicated in the table below
Nursing
problems
The assessment plan Rationale for the
assessment
Assessment findings
Pain Open ended questions:
 Has your pain been
occurring constantly
or it occurs when you
try to make some
movements?
 Where can you range
If the pain is not
controlled, it might
lead to further clinical
complications
The pain is moderate,
morphine will be used
to control it

Nursing Assessment, Case Study of Mr. William 6
your pain in a scale of
1-10?
 Can you say that
morphine has been
effective in
controlling your pain?
Additional Assessment:
The pain levels will be
assessed on regular basis
Electrolyte
imbalance
Open ended questions:
 Do you experience
fatigue or
unconsciousness
sometimes?
 Have you experienced
difficulties when
breathing or irregular
heartbeats at any
given moment?
 Have you experienced
visionary issues like
chest pains or
dizziness at any given
moment?
Additional Assessments:
Electrolyte balance will be
monitored in regular intervals
Assessment at this
juncture is important to
avoid critical risks and
guarantee patient safety
Electrolyte level is
considerably normal

Nursing Assessment, Case Study of Mr. William 7
Stress and
anxiety
Open ended questions
 How often do you feel
anxious?
 Do you experience
upsets out of
nowhere?
 Do you experience
pains in chest or
abdomen
 Have you experienced
frequent pains and
infections?
Additional assessments:
Lung auscultation will be
assessed also
Stress and anxiety
worsens the condition
of a patient and
complicate the healing
process.
Stress and anxiety
levels are high in the
case of Mr. William
Hypertension Open ended questions:
 Do you experience
fatigue or
unconsciousness
sometimes?
 Have you experienced
difficulties when
breathing or irregular
heartbeats at any
given moment?
 Have you experienced
visionary issues like
chest pains or
dizziness at any given
Blood pressure must be
managed because it
may lead to stroke and
other cardiovascular
complications
The blood pressure was
abnormal

Nursing Assessment, Case Study of Mr. William 8
moment?
Additional Assessments
Blood pressure will be
monitored in regular intervals
Bruises Open ended questions:
 Are your bruises
painful on touch?
 Are the bruises
bleeding?
 Do you experience
any variations of
temperature on the
skin around the
bruises?
The assessment will
allow the identification
of any abnormalities
and blood supply issues
on the bruises.
Bruises are not painful
and no changes in
temperature on the skin
cover around the
bruises
Tachypnea and Tachycardia vs Pain
Tachycardia is a condition in which the heart rate of a person is highly elevated, like a heart
rate which is more than 100beats per second. Tachypnea on the other hand describes the
condition of abnormal breathing rates like a breathing rate which is more than 20breaths/minute
(Berman et al., 2018). Severe pains in the body increases the blood pressure as well as the pulse
rate. This affects the heart rates, pulse rates, stress response and breathing patterns which in turn
causes tachypnea and tachycardia.
Co-morbid Nursing problems
There are a number of other nursing problems which have a direct link to tachycardia and
tachypnea. The most common ones are hyperventilation (deep and rapid breathing) and dyspnea
(shortness of breath). To assess hyperventilation, emotional attacks and panic history of a person
is considered. On the other hand, blood tests, medical history of lung infections or
cardiovascular diseases are used to assess dyspnea problem.

Nursing Assessment, Case Study of Mr. William 9
Part C
Nursing Assessment Frameworks
Assessment frameworks are very important in nursing professional because they enable
nurses to collect relevant data on patients. The data collected through assessment frameworks
ranges from psychological, sociological, spiritual to physiological data (Considine & Currey,
2015). This text will scrutinize both the holistic and focused assessment frameworks. Holistic
assessment framework is an assessment framework that focuses not only on the patient’s
physical health but also their emotional, spiritual and mental health needs. This assessment
provides more valuable and precise data which is crucial in both diagnosis and planning stages
of healthcare.
Focused assessment framework on the other hand is an assessment framework which is used
to assess specific systems in the body under the guideline of the patient’s health conditions. It is
a very useful framework in the acute care department. This framework allows nurses to utilize
their clinical judgements to assess the condition of a patient. In the case of Mr. William, this
framework has been very useful because of the different body systems which were involved in
the assessment process, such as respiratory, cardiovascular and nervous systems (Jarvis, Forbes
& Watt, 2011).
According to the Nursing and Midwifery Board of Australia 2016, comprehensive and
systematic assessments are very important in treatment because they guarantee the safety of
patients. The assessments chosen by nurses must therefore be highly effective and results
oriented. Holistic assessment framework has many advantages to both the nurse and the patients.
On the side of nurses, it allows them to identify and analyze all the patient needs without
limiting them on physical needs only. This enables the nurses to provide patient centered care to
their patients. It has one main weakness: due to its limited scope of evidence, identifying
possible risk factors is a challenge.

Nursing Assessment, Case Study of Mr. William
10
Focused assessment framework on the other hand emphasizes on the physiology of patients
and ignores the other factors such as psychological and social aspects of a patient. This is the
main weakness of this framework because it inhibits the provision of patient centered care. Its
main advantage lies on the fact that it provides in-depth assessment of all the physical aspects of
human body systems. For that matter, risk vulnerabilities can be identified easily to come up
with improved care plans with minimum faults (Osborne et al., 2015).
As a future registered nurse, understanding systematic and comprehensive frameworks is
very important. This is because they will enable me monitor and govern all nursing parameters
which are related or have morbidity with clinical issues. This is in consideration to the fact that
clinical injuries on one body system may affect other body systems as well. When providing
acute care to patients, other clinical aspects tends to arise out of blues, a systematic approach
helps avoid such kind of errors and guarantee quality health services (Osborne et al., 2015).
Besides physical assessments, there are patients who will require cultural, emotional and
spiritual interventions which can only be achieved through systematic assessments.
In summary, the report has revealed the importance of assessment frameworks in the
nursing profession. The main importance of assessment frameworks has been identified as the
safety of patients. Secondly, they have been identified as catalysts to quick recovery of patients
along with quality care approach.
References
Berman, A., Kozier, B., Erb, G. L., Snyder, S., Levett-Jones, T., Dwyer, T., ... Stanley, D.
(2018). Kozier and Erb’s fundamentals of nursing: concepts, process and practice (4th
ed.). Pearson Australia
Considine J, Currey J. (2015) Ensuring a proactive, evidence-based, patient safety approach to
patient assessment. Journal of Clinical Nursing, 24(1-2), 300-7. doi:10.1111/jocn.12641

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Jarvis, C., Forbes, H., & Watt, E. (2011). Jarvis’s physical examination and health assessment
(2nd Aust and NZ Edition). Elsevier Australia.
Nursing and Midwifery Board of Australia. (2016) Registered Nurses Standards For Practice:
Standard 4. Comprehensively conducts assessments. Retrieved from
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines- Statements/Professional-
standards/registered-nurse-standards-for-practice.aspx
Osborne, S., Douglas, C., Reid, C., Jones, L., & Gardner, G. (2015). The primacy of vital signs -
Acute care nurses' and midwives' use of physical assessment skills: A cross sectional
study. International Journal of Nursing Studies, 52(5), 951-962.
doi:10.1016/j.ijnurstu.2015.01.014

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