Emergency Room Assessment

According to the scenario, Mr. Smith was admitted into the hospital due to fever, fatigue, abdominal pain, loss of appetite, nausea, and vomiting. During the emergency room visit, an assessment was performed on the patient to collect information. According to Dr. Carol Taylor’s Fundamentals of Nursing: The Art and Science of Person-Center Nursing Care: 8th Edition, an assessment is done to collect, “all pertinent patient information… to develop a comprehensive and effective plan of care” (Taylor, 2015, 232). In other words, Mr. Smith needed an assessment to measure his health status (Taylor, 2015, 233). After his assessment was completed, it was determined that Mr. Smith’s blood pressure was normal; pulse was 110 beats per minute; respiratory …show more content…
In addition, Mr. Smith also had yellow eyes and an enlarged liver. The assessment also included the patient’s medical record which provides the patient’s medical, social, and family history. Lastly, lab tests performed determined that Mr. Smith has Hepatitis B. Taylor’s Fundamentals of Nursing: 8th Edition explains that, “reports of laboratory studies…include [with] objective data (observable and measurable data that can be seen, heard, felt, or measured by someone else) that can [can] either confirm or conflict with data collected during the.. examination” (Taylor, 2015, 241-242). The objective symptoms the patient exhibited include yellowing of the eyes, enlarged liver, and fever. I believe that the objective symptoms and laboratory tests are the most pertinent information because they confirm the patient’s health status and that he is very ill with Hepatitis B. The patient’s social and family history is also important since it allures to past drug use and that the patient sexually active. The patient’s subjective symptoms (which is what he can only perceived) is also important since loss of appetite, nausea, fatigue, and vomiting are symptoms of Hepatitis B; and it signals how severe the patient’s condition is (Taylor, 2015, …show more content…
Taylor’s textbook explains that planning, “is to design a plan of care with and for the patient that… results in the prevention, reduction, or resolution of patient health problems and the attainment of the patient’s health expectations” (Taylor, 2015, 277-278). First, the symptoms that Mr. Smith is currently exhibiting need to be relieved since they are affecting his health status and physiologic well- being (Taylor, 2015, 280-281). For instance, the patient’s fever, nausea and vomiting, and abdominal pain needs to be addressed. Then, the patient will need patient teaching on Hepatitis B; pathophysiology; means of transmitting the disease, symptoms, and medication regimen; and it is to be explained in simple terms he can understand. After Mr. Smith receives patient education, he will be fully knowledgeable about Hepatitis B; and understand and adhere to his treatment plan. In addition, he will be taught and will learn ways to break the chain of transmission to maintain safety needs, like practicing safe sex, avoiding drug use, and sharing needles. Mr. Smith will also receive education on eating healthy and maintaining his weight. After he receives nutritional education, Mr. Smith will be able to eat healthy and maintain his weight after being discharged from the hospital. Also, he will receive education on the dangers of drug use. Lastly, Mr. Smith and his family