Assess Client and Manage Patient for Respiratory-myassignmenthelp

Question: Discuss about theAssess Client and Manage Patient for Respiratory. Answer: 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) 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 Jakes emotion and view after fall. This will to gather motivation of patient for recovery and mental capacity to handle challenges in the treatment process. 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 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). 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-fowlers 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). 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. Nursing care plan for Jake Taylor Actual Nursing problems Interventions Rationale Evaluation 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 patients 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. 2017). This intervention is beneficial to prevent risk of complication in patients 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 (Corts, 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 abdominal pain and fall injuries Communicate with patient and identify perception and feelings of anger or grief in patient Orient patient to routine and expected activities Communication with patient is important to know about coping capability of patient and reduce symptoms of depression. Orienting to routine activities distract patients from emotional stress and lead to improvement in signs of depression (Jayasinghe et al. 2014) Patients expression about current and future worries will help to take adequate steps to mitigate symptoms 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/muscular 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 patient Implement hand hygiene and infection control intervention for Jake Due to fall, Jake is dependent on major activities of daily 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) Infection control will minimize development of other complications 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 pain 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. 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 Discharge planning: 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). 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 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) . 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). 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., Berros-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. Corts, 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. 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