Nursing Report: Assessing Clients and Managing Patient Care - ED

This nursing report details the assessment and management of a 55-year-old male, Jake Taylor, admitted to the ED after a fall. The report prioritizes nursing assessments, including respiratory, GIT/metabolic, CVS, CNS, renal, skin, psychological, and discharge evaluations. It outlines essential assessments for left-sided chest pain, utilizing the HEART score and PQRST tools, and details immediate nursing interventions. A comprehensive nursing care plan addresses actual and potential nursing problems, offering interventions, rationales, and evaluation methods. The plan covers pain management, risk of ineffective tissue perfusion, fluid volume, heart failure, and anxiety. The report concludes with discharge planning, emphasizing medication education, dietary guidance, mobility precautions, and lifestyle modifications, such as avoiding smoking and alcohol, to prevent further complications.

Running head: ASSESS CLIENT AND MANAGE PATIENT CARE
Assess client and manage patient care
Name of the student:
Name of the University:
Author’s note

1ASSESS CLIENT AND MANAGE PATIENT CARE
Part 1:
Jake Taylor, a 55 year old male roof gutter installer was admitted to the ED via
ambulance following fall from the roof (from the height of two meters). His major complain was
pain in the abdomen and left shoulder pain. The nursing assessment priority for Jake from most
urgent to least urgent is as follows:
Respiratory- The most urgent nursing assessment priority is to conduct respiratory assessment of
patient to get information related to respiratory rate, auscultation of the lungs and oxygen
saturation rate of patient after fall. This is important because high falls often cause soft tissue
injury to lungs and may lead to subdural hematoma (Granhed et al. 2017). Hence, respiratory
assessment may give idea about level of respiratory problem or soft tissue injury in patient after
fall.
GIT and metabolic- This assessment is important for patients because Jake has mainly
complained about abdomen pain since admission to the ED. During this assessment, information
about past medical history, current lifestyle and medication and nutritional uptake is necessary to
determine the impact of any of these factors in contributing to stomach pain. It may indicate
about intolerance to some food or side effects of medication since Jake is talking many
medications. Onset, intensity and duration of pain will help to determine the correct medication
for patient too (Macaluso and McNamara 2012).
CVS- As the patient sustained fall from high height, checking vital signs like blood pressure and
heart rate is necessary to identify symptoms of anxiety and heart rate variability in patients after
fall. It may also give idea about the cardiovascular causes of falls (Palvanen et al. 2014)

2ASSESS CLIENT AND MANAGE PATIENT CARE
CNS- CNS assessment is important for Jake because fall from high height might have resulted in
brain injury in patient and it may help to predict level of consciousness in patient after fall. This
assessment 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 might
indicate about fluid balances status and urinary pattern after fall (Gallagher, Rapuri and Smith
2007).
Skin- Skin assessment is also a vital assessment for patients as he might have sustained several
skin 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 emotion
and view after fall. This will to gather motivation of patient for recovery and mental capacity to
handle challenges in the treatment process.
Part 2:
1. The essential nursing assessment for patient with left sided chest pain will be to collect
HEART score of patients as it will give data related to history, ECG, age, risk factors and
troponin (Six et al. 2013). The data can help to determine the ischemic nature of chest
pain in Jake. The PQRST assessment tool can also help to determine the main factor and
severity of pain patient. As Jake has history of hypertension, the BP assessment of patient
will also be essential to determine the cardiovascular risk status of patient and
cardiovascular cause of chest pain (Daskalopoulou et al. 2015).
Left sided chest pain is an indication of heart disorder. Blood clot in the lung or
pneumothorax can also lead to sharp pain and chances of this are high in Jake due to fall. Te

3ASSESS CLIENT AND MANAGE PATIENT CARE
immediate nursing intervention for left sided chain pain will include immediate vital sign
assessment of patient and making Jake sit in a semi-Fowler position to review pain. Oxygenation
and 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 risk
stratification component responsible for chest pain and so it can help the clinician to
make accurate diagnostic and therapeutic choices for patients like Jake (Six, Backus and
Kelder 2008).
The main advantage of considering semi-fowler’s position for patient with chest pain is that
it 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 is
ischemic in nature (Raut and Maheshwari 2016).
3. Two actual nursing complications due to left sided chest pain include shortness of breath
in patient and risk of heart failure in patient. The two potential nursing complications
evident due to left sided chest pain are development of precarditis and postinfarction
angina in patient.
Part 3: Nursing care plan for Jake Taylor
Actual Nursing
problems
Interventions Rationale Evaluation

4ASSESS CLIENT AND MANAGE PATIENT CARE
1. Complain of
left sided chest
pain in patient
 Monitor and
document
characteristics,
intensity and
heart rate or BP
changes due to
pain
 Review past
medical history
of myocardial
infarction in
patient
This nursing
intervention will give
idea about level of
anxiety and intensity of
pain in patients (Than
et al. 2014).
Pain documentation is
crucial for resolution of
patient’s problem
2. Risk of
ineffective
tissue
perfusion due
to fall injury
and abdominal
pain
 Assessment of
skin, peripheral
pulse, edema
and vital signs
in patient
 Assessment of
GI function
Due to fall from high
height, injuries might
contribute to
pulmonary
complications in
patients and abdominal
pain. Hence, vital sign
and skin assessment is
critical to assess GI
dysfunction and other
complication in Jake
after falls (Morton et al.
This intervention is
beneficial to prevent
risk of complication in
patients

5ASSESS CLIENT AND MANAGE PATIENT CARE
2017).
3. Risk of excess
fluid volume
due to fall
 Auscultate
breath sounds
 Maintain fluid
intake in
patients
Auscultation is
beneficial in identify
and manage risk of
heart failure.
Maintaining fluid
intake is necessary to
enhance fluid retention.
Jake also take two cans
of beer everyday and
restricting the use of
beer is also necessary
for recovery of patient
(Platz et al. 2016)
Risk of heart failure
and circulatory
problem in patient can
be controlled
4. Discomfort in
patient due to
chest and
abdominal
pain
 Consider
repositioning
patients and
proving
analgesics
Positioning will
facilitate airway
management in patient
and analgesics will
cause pain relief
(Cortés, DiCenso and
McKelvie 2015)
It is an effective
intervention to
minimize discomfort
and intensity of pain in
Jake
5. Anxiety or
fearful attitude
in Jake due to
chest and
 Communicate
with patient and
identify
perception and
Communication with
patient is important to
know about coping
capability of patient
and reduce symptoms
Patient’s expression
about current and
future worries will help
to take adequate steps
to mitigate symptoms

6ASSESS CLIENT AND MANAGE PATIENT CARE
abdominal
pain and fall
injuries
feelings of
anger or grief in
patient
 Orient patient to
routine and
expected
activities
of depression.
Orienting to routine
activities distract
patients from emotional
stress and lead to
improvement in signs
of depression
(Jayasinghe et al. 2014)
of anxiety in patient
6. Acute
abdominal
pain in patient
Abdominal pain in patient
might also be caused by
diarrhea. Hence, it is
necessary to assess bowel
movement in patient
Bowel movement will
help to determine the
appropriate food and
medications needed for
patient to reduce pain
Bowel pattern
assessment is critical to
proactively assess
symptoms of nausea,
constipation and
diarrhea in patient
7. Risk of bone
or muscle
injuries due to
fall
 Conduct
skeletal/muscul
ar assessment of
patient
Clinical assessment
would help to evaluate
the severity of muscle
or bone injury
On the basis of
severity of injury, the
nurse can consult the
clinician regarding the
use of conventional
treatment option of
medication or going for
physiotherapy (Phelan
et al. 2014)
8. Prevent
infection in
 Implement hand
hygiene and
Due to fall, Jake is
dependent on major
activities of daily
Infection control will
minimize development
of other complications

7ASSESS CLIENT AND MANAGE PATIENT CARE
patient infection control
intervention for
Jake
living. This may
increase the risk of
infection in patient.
Hence, maintaining
adequate hand hygiene
and infection
prevention technique is
essential to prevent
infection (Anderson et
al. 2014)
in Jake
Potential nursing problems
Potential nursing
problems
Interventions Rationale Evaluation
Risk of heart attack in
patients
 Regular
PQRST
assessment is
necessary to
analyze
different
factors
contributing to
Routine assessment of
chest pain is critical to
reduce the risk of
myocardial infarction or
heart attack in patient
PQRST is a structured
assessment method to
identify the
characteristics, intensity
and cause of chest pain.

8ASSESS CLIENT AND MANAGE PATIENT CARE
pain
Increased dependence in
activities of daily living
Provide assistance to
Jake while walking,
moving, dressing and
going to washroom
Support is ADLs is
critical to complete
daily life activities and
reduce risk of fall in
health care setting
It is most effective step
to support patient during
difficulties in ADLs.
Low physical activity
and risk of obesity
related complication in
patient
Provide guidance in
physical therapy and
moderate exercise
intervention
This I s essential to
maintain minimum level
of physical activity in
patients
Moderate exercise
improved quality of life
of critically ill patients
Part 4:
Discharge planning:
1. Jake is on certain medications currently. Hence, it will be necessary to educate patient
about side-effects and precautions needed for taking the medication. This is necessary
because Jake is complaining about stomach pain and certain medications may also
contribute to constipation (Ho et al. 2014).
2. Other discharge education necessary for Jake will to provide information about types of
diet and fluid intake. This is necessary because to control stomach and complicated
outcomes in patient
3. As fall from high height has also affected mobility of Jake, it will be necessary for Jake to
take precaution while moving from one place to another. Hence, assistive device and
ways of using them will be taught to Jake (Doherty‐King et al. 2014) .

9ASSESS CLIENT AND MANAGE PATIENT CARE
4. As Jake has chest pain and he is a patient with heart disorder, another important discharge
education will be forbid patient from smoking and consuming bear. This is necessary to
reduce further complications (Morris et al. 2013).

10ASSESS CLIENT AND MANAGE PATIENT CARE
Reference
Abbas, A.D., 2014. Evaluation Of Nurses Practices Concerning Chest Pain Management For
Patients In The Emergency Unit. Kufa Journal for Nursing Sciences, 4(1).
Anderson, D.J., Podgorny, K., Berríos-Torres, S.I., Bratzler, D.W., Dellinger, E.P., Greene, L.,
Nyquist, A.C., Saiman, L., Yokoe, D.S., Maragakis, L.L. and Kaye, K.S., 2014. Strategies to
prevent surgical site infections in acute care hospitals: 2014 update. Infection Control & Hospital
Epidemiology, 35(S2), pp.S66-S88.
Cortés, O.L., DiCenso, A. and McKelvie, R., 2015. Mobilization Patterns of Patients After an
Acute Myocardial Infarction: A Pilot Study. Clinical nursing research, 24(2), pp.139-155.
Daskalopoulou, S.S., Rabi, D.M., Zarnke, K.B., Dasgupta, K., Nerenberg, K., Cloutier, L.,
Gelfer, M., Lamarre-Cliche, M., Milot, A., Bolli, P. and McKay, D.W., 2015. The 2015
Canadian Hypertension Education Program recommendations for blood pressure measurement,
diagnosis, assessment of risk, prevention, and treatment of hypertension. Canadian Journal of
Cardiology, 31(5), pp.549-568.
Doherty‐King, B., Yoon, J.Y., Pecanac, K., Brown, R. and Mahoney, J., 2014. Frequency and
duration of nursing care related to older patient mobility. Journal of Nursing Scholarship, 46(1),
pp.20-27.
Gallagher, J.C., Rapuri, P. and Smith, L., 2007. Falls are associated with decreased renal
function and insufficient calcitriol production by the kidney. The Journal of steroid biochemistry
and molecular biology, 103(3), pp.610-613.