Emergency Department Case Study: Patient Assessment and Care

This case study analyzes the urgent management of a patient presenting in an emergency department, focusing on the application of the A-E algorithm (Airway, Breathing, Circulation, Disability, Exposure) for initial assessment and treatment. The case involves a 20-year-old male, Mr. Corey Knight, who was involved in a car accident and presents with multiple injuries, including potential asthma exacerbation and a fractured femur. The essay details the nurse's role in assessing and managing the patient's airway, breathing, circulation, disability, and exposure, including vital sign analysis, administration of medications, and interventions like oxygen supplementation and fluid resuscitation. Furthermore, it examines the sociocultural, psychological, biological, and political-economic factors influencing the patient's discharge planning and recovery, such as alcohol use, family support, mental health concerns, and access to healthcare. The analysis emphasizes the importance of holistic and collaborative care to ensure optimal patient outcomes and addresses the need for patient education, follow-up, and rehabilitation strategies during discharge preparation.

Running head: CASE STUDY 1
Case Study
Student Name
Institutional Affiliation

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Case Study
Introduction
An emergency department is a section in the hospital setting that specializes in
emergency medicine and handling acute patients who need immediate management and are
susceptible to complications (Hallifax, 2017). This department applies the principles of priority
care by triaging the patients requiring urgent medication to be seen first (Mollaoğlu, & Çelik,
2016). The department is comprised of all medical professions that help in managing the patient
in the acute phase. Ongoing care is not provided in the emergency department hence patients are
transferred to the wards for further management.
Clinicians receiving the patient are required to assess the patient using the A-E algorithm
to determine the priority patient needs hence plan urgent management. The Airway, Breathing,
Circulation, Disability, Exposure approach enables the clinicians to assess the situation of the
patient and manage them before making the definitive diagnosis (Olgers, Dijkstra, Drost-de
Klerck, & Ter Maaten, 2017). This essay aims to discuss in depth the urgent management of a
patient presenting in the emergency department and analyze the social, biological, psychological,
and political-economic factors that need to be considered during patient discharge. The aim will
be achieved by utilizing the A-E algorithm in patient management and analysis of the patient
during release to determine the factors to be addressed.

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Nursing assessment
Airway
The nurse has a role in assessing the patency of the airway in trauma patients who arrive
at the emergency department. Maintaining a patent airway and ensuring adequate ventilation
leads to the prevention of hypoxia and hypercapnea. Hypercapnea leads to a reduced level of
consciousness and respiratory acidosis, which can result in end-organ damage. In trauma
patients, the nurse has a role in immobilizing the neck to prevent further damage to the cervical
spine (Parker, & Magnusson, 2016).In the scenario of Mr. Corey Knight, the patient was hit by a
car, thrown on the bonnet, and fell on the roadside. Due to the nature of the injury, the patient is
assumed to have sustained multiple injuries. The patient had Asmol inhaler in her pocket, a sign
that she is asthmatic. Due to the stress of the accident, an asthma attack might be triggered. The
nurse should assess for signs of airway inflammation by listening to breath sounds concentrating
on the presence of a wheeze.
The nurse should assess for maxillofacial and neck injuries to confirm the presence of a
foreign body in the airway; hence, the nurse should monitor for the presence of any blood,
secretions, or debris in the airway and perform suctioning to clear the airway. Partially
obstructed airway presents with noisy breathing and increased the effort of breathing. The nurse
should instruct the patient to verbalize a series of numbers with his hands on the back to test
fremitus since blocked vibrations indicate an obstructed airway. In an emergency setting, the
nurse has the role of assessing the airway and use the head-tilt and chin-lift criteria to open the
airway (Kuszajewski, O'Donnell, Phrampus, Robey III, & Tuite, 2016). The nurse should
remove any obstruction to ensure sufficient air entry, and in cases when a patent airway cannot

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be achieved, the nurse has a role in calling the specialist to obtain a surgical airway to facilitate
breathing. Regular evaluation of the state of the airway is critical to prevent complications.
Breathing
Breathing is movement of air in and out of the lungs to facilitate gaseous exchange. It is
essential in the provision of oxygen to the cells for respiration and helps in the elimination of
wastes. In the case of Mr Knight, the nurse has a role in inspecting the breathing technique of the
patient. The nurse should listen to the patient's breathing, observe the movement of the chest
walls, presence of intercostal and sternal retractions, and if the patient is using accessory muscles
in breathing ((Smith, & Rushton, 2015). He has a respiratory rate of 24b/min, which is relatively
higher compared to the standard rate of 12-20 b/min at rest. Palpation enables the nurse to assess
fremitus, lung expansion, and skin abnormalities. The nurse should assess for pain and
tenderness to confirm whether the patient sustained a fracture of the ribs. The nurse should assess
the symmetry in the expansion of the chest to identify the affected side of the chest. In
percussion, the nurse should percuss for resonant sounds. Hyperesonant sounds will indicate the
patient has a pneumothorax while dull sounds indicate the presence of pleural effusion. The
patient is saturating at 94%, which is less than the normal SpO2 levels of 97-100%. This
suggests that the patient has an ineffective breathing pattern.
The nurse should auscultate for breath sounds to check for any adventitious sounds. The
priority management is ensuring effective breathing has been established to prevent
complications. The nurse should position the patient in a semi-fowler position to promote
easiness in breathing. The patient is complaining of pain in the right side of the chest and is

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portraying shallow breathing; hence, the nurse administered an opioid analgesic to ease the pain,
relieve anxiety, and promote breathing (Häske et al., 2017). The nurse should administer
prescribed inhaled medications to prevent an asthma attack while taking more history from the
patient regarding asthma. In case of hyper resonant sounds during percussion, the nurse should
inform the physician for urgent decompression. The nurse should administer supplemental
oxygen to the patient and evaluate the patient’s condition timely.
Circulation
Circulation is the movement of vessels aided by the pumping of the heart muscle, through
the blood vessels to provide nutrients to the body tissues and in turn, extract waste products. In
the assessment of circulation, the pulse rate is an essential recording. The pulse recorded was 122
beats per minute, which is higher than the standard of 60-100 beats/min. The nurse should
compare the pulses of both sides of the body to confirm if they are of the same strength and
frequency (Bang, Goyal, & Liebeskind, 2015). The nurse has a role in assessing the patient and
identifying any open or closed wounds that might be bleeding. The immediate management of a
bleeder is to apply cold compression dressing to arrest the bleeding. Stitching is another way to
closing up a wound to minimize blood loss that can lead to shock.
Body temperature is another indicator of the body's circulation state as it is maintained by
the circulating blood. The nurse should feel the skin of the patient to assess whether there are
colder areas than others. The body temperatures recorded was 35.9⁰C that is low compared to the
standard of 36.5-37.5⁰C. From the vital signs, it is evident that the patient lacks sufficient
circulation (Bisson, Carpenter, Snyder, & Cappuccino, 2017). The nurse should observe the skin
color for paleness and perform a capillary refill assessment since it determines perfusion in body

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tissues. The nurse should auscultate for heart sounds and measure blood pressure. The blood
pressure recorded was 90/60mmHg, which is low compared to the normal ranges. From the
electrocardiogram report, the patient is observed to be having regular tachycardic heartbeat with
signs of cardiac muscle ischemia due to ventricular hypertrophy. The nurse should insert a
urinary catheter to monitor urine output to monitor the kidney function. To correct the fluid
deficit, the nurse should elevate the patient's legs to facilitate the venous return and administer
intravenous fluid to increase volume.
Disability
Disability in a patient is caused by factors that reduce the level of consciousness. In the
case scenario, the nurse has a role in reassessing the ABCs of the patient since they are the
significant causes of disability. The nurse should assess whether the airway is still patent,
whether the patient has effective breathing and the circulation state. Pupil reaction to light is
indicative of a patient's state of consciousness. The nurse has a role in assessing the pupil size
and bilateral response to light. The nurse should perform regular rating using the Glasgow coma
scale (Abedzadeh–kalahroudi, Razi, Sehat, & Asadi-Lari, 2016). On arrival, the patient's GCS
was 14. The nurse should monitor for signs of decreasing GCS as it may indicate a severe
complication. The patient had alcohol in her pocket; the nurse should assess the level of
intoxication that may cause disability and also monitor for any signs of toxicity from the
morphine administered. In the management of opioid toxicity, the nurse will administer naloxone
to reverse the depressive symptoms. Hypoglycemia is another cause of disability; hence, the
nurse will perform a random blood sugar test and administer 10% intravenous glucose solution
until the blood glucose level is normal.

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Exposure
In this step of patient assessment, the nurse identifies the extent of exposure to the
trauma. The nurse performs a full-body inspection while maintaining patient dignity to determine
the degree of injury and the size of muscle damage (Spinazzola et al., 2017). The whole body is
exposed for the nurse to perform an extensive physical exam bearing in mind not to expose the
patient to cold. During the inspection, the nurse should assess for bruises and areas of
tenderness, including the calves, and monitor the catheter output if there is blood in the urine that
can be a sign of trauma. In the inspection of the limb, the nurse will assess the presence of
bleeding and calculate the amount of blood loss. Due to the impact of the hit at 40km/hr and the
fact that the patient was thrown to fall, the patient sustained several lacerations and bruises with
fracture femur (Richardson, & Carter, 2017). The nurse should immobilize the limb to prevent
further injuries and arrest any bleeding by applying cold compressions. The nurse should
evaluate the patient after the interventions to assess the patient's state to minimize complications.
Discharge preparation
In the discharge of Mr. Kninght, the nurse should provide adequate training so as the
patient will attain full recovery. The nurse, in collaboration with other clinicians, has a role in
educating the patient and maintaining follow-up and rehabilitation to promote the quality of
patient outcomes (Page, Lederman, Kelly, Barry, & James, 2016). A patient is a functional
system, and many factors influence the response to restoration to health. The nurse should hence
ensure the issues are factored in to provide holistic and collaborative discharge.
Sociocultural factors

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Social factors include; access to education, the amount of income, nature of residence,
and availability of food. Culture is the way of life of people. Mr. Knight is a 20-year-old man
who has a low-income job. He lives with his flatmate and reports to have not gone to college and
is an alcoholic. During the discharge after fractured femur, the nurse should educate the patient
on the importance of withdrawing alcohol use during the healing period. Alcohol affects bone
healing as it impairs the body's defense mechanism against pathogens, which can cause infection.
The nurse should educate the patient on the importance of a balanced diet in bone healing and
advise him on the importance of family during the healing period (Thoma, & Waite, 2018). The
patient reports to have poor relations with the family members, and he is not married. Lack of
family support to the young patient made it difficult for him to settle the hospital bill and also
seek further rehabilitative treatments. The nurse, in collaboration with the hospital social worker,
will help wave charges during discharge and in the next hospital visits.
Psychological factors
Psychological factors affect the way of thinking of a person and their drive towards
seeking health and wellness. They involve stress, depression, hostility at home or work, and
hopelessness (Mancuso, Duculan, R., Craig, & Girardi, 2018). Mr. Knight had Ritalin in his
pocket, which he reports to use it to manage symptoms of narcolepsy. Due to work stress and
social stress, he developed depression and hopelessness and used to experience excessive sleep
even in the workplace. He reports being working very hard, with little pay due to his lack of
experience. Stress and depression affect one's drive to seek medical attention until recovery. He
needs sessions of physiotherapy to enable him to recover fully and walk without crutches. The
nurse will involve the hospital psychologist to help in patient therapy sessions with other forms
of management before sending him home.

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Biological factors
These are genetic or inherited structural make up of a person that affects response to
health and disease. It involves the patient's age, sex, inherited conditions, and HIV status. It also
consists of the body’s response to healing and remodeling (Alimohammadi, Maleki, Shahriari, &
Chitsaz, 2015). The patient has no chronic conditions or any history of chronic diseases in the
family. For normal limb function to be regained; proper wound care and physiotherapy should be
performed. Infection in the healing bone delays bone healing since infected ends do not remodel
but instead increase the size of the wound (Westgeest et al., 2016). Microorganisms can invade
the bloodstream and lead to multi-organ damage. The discharging nurse, in collaboration with
the surgical team, will examine the patient before discharge to ensure the fracture is free of
infection signs and give the patient appointment dates for continuous monitoring. The nurse will
involve the physiotherapist in the follow up of the patient to educate the patient on the use of
crutches and practice range of motion exercise to retain limb function.
Environmental and politico-economic factors
These are factors surrounding an individual that may affect health-seeking and recovering
from illness. They include income, housing conditions, exposure to hazards, physical activity
lacking, malnutrition, and legal issues. Mr. Knight has a low-income rate depending on the
nature of work he is partaking. He has experienced fracture to the limb; hence, it will limit the
physical activity (Abdel-Shafy, & Mansour, 2016). The nurse should educate the patient on the
disadvantage of bed rest as it may lead to complications such as deep vein thrombosis. The nurse
will inform the patient on low minimum wage rates and involve the local authorities to help the
patient to receive adequate payment for work done.

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Conclusion
Holistic and collaborative patient care offers a basis for evidence-based care to promote
quality patient outcomes and incorporates other disciplines to provide holistic patient
preparation. In the emergency department; the A-E algorithm is applied as it systematically
prioritizes patient assessment and cares in acute conditions to prevent disease progression and
complication. The department is comprised of an interdisciplinary team specialized to manage
the patient acutely and stabilize then transfer to the relevant units. The hospital is a system made
of interdependent sub-systems named the departments. After patient recovery, he is discharged
home on follow up depending on the final evaluation and patient readiness. The discharging
nurse has a role of considering the political-economic, sociocultural, environmental and
psychological issues during the discharge process

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References
Abdel-Shafy, H. I., & Mansour, M. S. (2016). A review on polycyclic aromatic hydrocarbons:
source, environmental impact, the effect on human health, and remediation. Egyptian
Journal of Petroleum, 25(1), 107-123.
Abedzadeh–kalahroudi, M., Razi, E., Sehat, M., & Asadi-Lari, M. (2016). Psychometric
properties of the world health organization disability assessment schedule II-12 Item
(WHODAS II) in trauma patients. Injury, 47(5), 1104-1108.
Alimohammadi, N., Maleki, B., Shahriari, M., & Chitsaz, A. (2015). Effect of a care plan based
on Roy adaptation model biological dimension on stroke patients’ physiologic adaptation
level. Iranian journal of nursing and midwifery research, 20(2), 275.
Bang, O. Y., Goyal, M., & Liebeskind, D. S. (2015). Collateral circulation in ischemic stroke:
assessment tools and therapeutic strategies. Stroke, 46(11), 3302-3309.
Bisson, L. J., Carpenter, B., Snyder, A. K., & Cappuccino, H. (2017). Systemic hypothermia as
treatment for an acute cervical spinal cord injury in a professional football player: 9-year
follow-up. Am J Orthop, 46(2), E79-E82.
Hallifax, R. (2017). Pneumothorax. Acute Medicine: A Practical Guide to the Management of
Medical Emergencies, 2(1), 399-401.
Häske, D., Böttiger, B. W., Bouillon, B., Fischer, M., Gaier, G., Gliwitzky, B., ... & Schempf, B.
(2017). Analgesia in Patients with Trauma in Emergency Medicine: A Systematic
Review and Meta-analysis. Deutsches Ärzteblatt International, 114(46), 785.

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Kuszajewski, M. L., O'Donnell, J. M., Phrampus, P. E., Robey III, W. C., & Tuite, P. K. (2016).
Airway Management: A Structured Curriculum for Critical Care Transport Providers. Air
medical journal, 35(3), 138-142.
Mancuso, C. A., Duculan, R., Craig, C. M., & Girardi, F. P. (2018). Psychosocial variables
contribute to the length of stay and discharge destination after lumbar surgery
independent of demographic and clinical variables. Spine, 43(4), 281-286.
Mollaoğlu, M., & Çelik, P. (2016). Evaluation of emergency department nursing services and
patient satisfaction of services. Journal of clinical nursing, 25(19-20), 2778-2785.
Olgers, T. J., Dijkstra, R. S., Drost-de Klerck, A. M., & Ter Maaten, J. C. (2017). The ABCDE
primary assessment in the emergency department in medically ill patients: an
observational pilot study. Neth J Med, 75(3), 106-11.
Page, J. S., Lederman, L., Kelly, J., Barry, M. M., & James, T. A. (2016). Teams and teamwork
in cancer care delivery: Shared mental models to improve planning for discharge and
coordination of follow-up care. Journal of oncology practice, 12(11), 1053-1058.
Parker, M., & Magnusson, C. (2016). Assessment of trauma patients. International journal of
orthopaedic and trauma nursing, 21, 21-30.
Richardson, A., & Carter, R. (2017). Falls in critical care: a local review to identify incidence
and risk. Nursing in critical care, 22(5), 270-275.
Smith, J., & Rushton, M. (2015). How to perform a respiratory assessment. Nursing Standard,
30(7), 34.