Systematic Nursing Assessment Case Study
Nursing care mainly focuses on the patient’s physical care, which allows nurses to be with their patients for much longer than many other health professionals. Systematic patient assessment is an integral part of a nurse’s job as it permits patient care to be prioritized according to severity of condition, and also molds the basis of care plans (Anderson, 1998). Through early detection of a deteriorating patient, appropriate treatment can be elicited, which could prevent adverse events and potentially save a patient’s life.
Patient assessment is an ongoing process that is conducted throughout the patients stay, with the frequency dependent on the patient’s overall status (Stoy, 2001). If assessment is not conducted thoroughly, vital information may be missed which may impact on the patients overall progress. A detailed systematic assessment is comprised of a primary survey: which aims to identify and treat life threatening conditions, and a secondary survey: which includes a detailed health history and a head to toe assessment (Wardrope & Mackenzie, 2004).
This paper relates systematic patient assessment to a clinical case study: Mr. Brown, a 72-year-old male is admitted to ED with increasing SOB on exertion. Throughout the paper Mr. Brown’s symptoms will be coupled to appropriate nursing interventions, as outlined by the appropriate literature. The first assessment to be conducted is the primary survey, which involves the identification of immediately life threatening conditions, coupled with appropriate nursing interventions (Allen, 2004). It should be commenced immediately upon contact with the patient, as well as any subsequent interactions.
The primary survey is an objective assessment, and follows the pneumonic DRsABCDE (BetterHealth, 2013). The primary survey begins with “D” and involves the health care provider assessing for dangers to self, the patient, or others. Dangers can include things such as liquid spills, broken glass, loose cables, and even distressed family members (AlscoFirstAid, 2013). In the case study, Mr Brown was sitting upright in bed with no dangers reported; therefore we are able to move onto the next stage. The second stage of the primary assessment, “R”, involves eliciting a response from the patient.
The response can be stimulated by any of the following: verbal means, touching of the shoulder, or a painful stimulus such as a sternal rub (BetterHealth, 2013). Mr Brown is eye opening to name, so he is classified as responsive. The nurse would postpone “s” sending for help at this stage, as it is unnecessary at the present time (AlscoFirstAid, 2013). Ensuring the patient has a patent “A” airway is vital; if it is compromised the patient will be unable to adequately perfuse the body with oxygen, which may result in cell death (Stoy, 2001).
Airway assessment ensures that the airway is clear and unobstructed from things such as food, vomit or the tongue (Domiguez, 1997). The quickest and easiest way to determine if the patients airway is patent, is by eliciting a verbal response (Safar et al. , 1959). If the airway was found to not be patent, then appropriate interventions must be carried out before continuing on through the assessment (Wardrope et al. , 2004). Mr Brown is ‘talking and orientated on walking’ indicating airway patency, thus it is acceptable to move on to “B”.
The “B” breathing assessment involves the evaluation of: respiratory rate, rhythm, depth of breathing and use of accessory muscles (AdvancedLifeSupportGroup, 2001). This ultimately assesses the effectiveness of breathing, which indicates if a substantial supply of oxygen is being supplied to the tissues. Upon inspection, Mr. Brown had equal rise and fall of the chest, however he was using his subcleidomastoid muscles, which is indicative of increased work of breathing (Banner et al. , 1995). Mr. Browns skin was also pale and moist to touch, which in combination with increased work of breathing can exemplify a state of hypoxia (Day et al. 2009). Hunter and Rawlings-Anderson (2008) report that the normal respiratory rate of healthy adults is between 12 and 20 breaths per minute. Mr. Brown’s respiratory rate is at 40 breaths per minute; therefore it is clear that he is tachypneic. If the patient is exhibiting increased work of breathing and an increased respiratory rate, Konica Minolta Sensing Inc. (2006) suggest using pulse oximetry to determine the patients oxygenation status. This assessment measures the level of saturation of the patients hemoglobin molecules. Konica Minolta Sensing Inc. 2006) indicate that normal SpO2 levels should be above 96% saturation, and anything less should be cause for alarm. Mr. Browns SpO2 levels were found to be 88% on room air, this combined with his increased work of breathing and respiratory rate suggest he is hypoxic and not perfusing his tissues adequately. Interventions must be put into place before the primary assessment can continue. To prevent Mr. Brown going into further respiratory distress, it would be appropriate to initiate oxygen therapy. Mr. Brown should be fitted with a Hudson mask on 100% oxygen with a minimum flow rate of 6L (Heffner, 2013).
The minimum flow rate will prevent Mr. Brown from rebreathing his expired CO2, and Hudson masks are readily available near the patient’s bedside (Heffner, 2013). The patient’s respiratory status should continually be assessed throughout oxygen therapy, and if the interventions are ineffective, further action is required. Bristow et al. (2000) report that respiratory distress is one of the most common reasons to call for the medical emergency team (MET). They go on to say that a MET call is usually elicited in response to a set of defined physiological abnormalities, which indicate that the patient’s health may be declining.
At this in the primary assessment it would be appropriate to initiate a MET call, as the patient appears to be in severe respiratory distress. According to Wardrope and Mackenzie (2004) a “C” circulation assessment is required to determine if a pulse is present, and whether the circulatory system is satisfactorily perfusing the tissues. They go on to say that a circulatory assessment can reveal signs of internal bleeding, hemodynamic shock, and sepsis. The pulse is assessed for rate, strength, rhythm, and equity on both sides (Anderson, 1998). A regular adult heart rate is eported to be between 60-100 beats per minute, and a regular blood pressure is 110-140mmHg systolic and 60-90 diastolic (Mancia et al. , 1983). Mr. Brown is slightly tachycardic with a heart rate of 105bpm, and hypertensive with a blood pressure of 150/90mmHg. Mr. Browns capillary refill time of 3s is considered within normal parameters, and he has a bilateral, strong radial pulse, which suggests his circulatory system is adequately reaching the periphery (Allen, 2004). As these results are not immediately life threatening, no interventions are required at this stage and the assessment can continue.
The next level of primary assessment involves an evaluation of the patient’s neurological status, checking for “D” disability. This step begins with assessing the patients level of consciousness with the AVPU scale: Alert, Verbal stimulus response, Painful stimulus response, Unconscious (McNarry & Goldhill, 2003). The assessment continues by checking if the patient’s pupils are equal size and responsive to light (PEARL), and checking the patients blood glucose (Wardrope & Mackenzie, 2004). Mr Brown was reported to be drowsy, but eye opening to a verbal stimulus, and his pupils were equal and responsive to light.
The patients blood glucose of 13. 4mmol/L was outside the normal parameters of 3-8mmol/L, however in the primary survey we are mainly concerned about hypoglycemia, and can revert back to this issue during the secondary assessment (Wardrope & Mackenzie, 2004). The “E” exposure portion of the primary survey addresses the patient’s external signs and symptoms. The patient’s temperature, skin appearance (including rashes/colour) and diaphoresis should all be assessed (Wardrope et al. , 2004). Mr Brown is afebrile, with a temperature of 36. 6°C, has no visible rashes, but is pale and moist to touch.
These conditions should be noted, and reassessed every 15 minutes to determine any changes, however as they are not life threatening it is safe to move on. The primary assessment is a cyclical process and should be constantly repeated throughout the patients stay in hospital. Continual monitoring assesses the effectiveness of interventions, and allows for subsequent changes to the patient’s care plan. Therefore it would be expected that the nurse should go through the primary assessment until all the requirements of each stage have been satisfied, before continuing on to the secondary assessment.
The secondary assessment comprises both subjective and objective data, in the form of a health history and a head-to-toe assessment (Anderson, 1998). A thorough health history is essential to assist the practitioner develop a diagnosis, and arrange a safe medication plan (Quilliam, 2011). The health history includes collecting the patients biographical data, reason for seeking health care, their past medical history, family history, current and past medications, and psychosocial histories (Stewart, 1990).
The first information collected in the secondary assessment is the patients demographic details, which includes name, date of birth, gender, address, phone number, and ethnic background (Quilliam, 2011). The extent of the demographic information supplied is as follows: Mr Brown is a 72-year-old male that lives in a large house with his wife. Secondly the patient’s reason for seeking healthcare must be explored including detailed symptom analysis (Anderson, 1998).
The pneumonic PQRST (Precipitating factors, Quality, Region and Radiation, Severity, Timing) is often used by health professionals to help the patient describe their symptoms in greater detail (Mulhall, 1977). ‘Precipitating factors’ explains the cause of the patient’s symptoms, whether the onset was sudden or gradual, and if any activities cause the symptom to get worse (Pollak et al. , 2005). ‘Quality’ allows the patient to qualitatively describe the feeling of the symptom, such as a heavy chest, crushing pain, stabbing or sharp (Mulhall, 1977). Region and radiation’ ask for the locations of the symptoms, and if they radiate to any other part of the body. ‘Severity’ allows the patient to describe their symptoms in a quantitative way, by rating the intensity out of 10 (Pollak et al. , 2005). ‘Timing’ refers to the pattern of the symptoms; if they are constant or experienced intermittently. Mr. Brown’s presenting complaint was increasing fatigue, increasing shortness of breath on exertion, non-productive cough, chest tightness and peripheral oedema. It should also be noted that Mr. Brown requires three pillows to sleep at night.
This is all the symptom information that was supplied for the patient. Past medical histories can help gain insight into the patient’s current condition. It should include past and present medical conditions, surgical procedures, congenital conditions, hospital admissions, trauma’s (both physical and emotional), immunizations, allergies and any other relevant information (Swartz, 2002). Mr. Brown’s past medical history shows he has a history of hypertension, hypercholesterolemia, and congestive cardiac failure (CCF). Mr. Brown may also have a history of obesity as his BMI upon admission is 35. , and a BMI >30 is classified as obese (DepartmentofHealthandAgeing, 2009). Collecting an up to date family history is important as many diseases carry a genetic component. Information collected in this segment includes diseases in the immediate family, as well as any premature deaths along with their age of death. There was no family history data supplied for Mr. Brown, therefore it will not be discussed. When collecting data about a patient’s medication it is important to remember over the counter, herbal and vitamin supplements, as well as the standard prescription medications.
Information regarding the dosage, length of use, and reason for use must also be documented (Quilliam, 2011). Mr. Brown was on Lasix 20mg BD (Bi-daily), Perindopril 2. 5mg BD, and Lipitor 40mg OD (once-daily). This is all the information documented about Mr. Brown’s medications. A psychosocial analysis should be undertaken to gain insight in to the patient’s living situation, and to assess the patient’s level of daily functioning, such as performing activities of daily life (ADLs) (Quilliam, 2011). This is a good opportunity to ask about the patient’s smoker status and alcohol intake.
It is also essential to check if the patient has any significant social support (Swartz, 2002). Mr. Brown is a retired schoolteacher that lives with his dependent wife in a large house, which he confined to most of the time. He is independent in his ADLs, but is the sole carer for his wife with osteoarthritis, as his three children live interstate. There is no information regarding his smoking status, and he is a social drinker. The final stage of the secondary assessment involves the collection of objective data, through a head-to-toe assessment. It is important that no significant information is overlooked.
This can be prevented by beginning with a general survey, followed by assessment of the head, neck, thorax, abdomen and lastly the extremities (Swartz, 2002). This process involves a comprehensive investigation of each body system using the four nursing techniques: inspection, palpation, percussion, and auscultation (Marcum & Killian, 2009). Inspection requires the use of sight and sound to observe the patient’s physical condition. Inspection is commonly used to assess the colour of the skin, and determine the presence of any rashes, bruises, lacerations etc. (Altman, 2004).
Palpation employs the use of the finger pads to gently depress the skin, assessing for underlying structures, moisture, tenderness or pulsations (Altman, 2004). Percussion involves tapping the fingertips on superficial structures, to assess the internal densities and consolidation through resonance of internal structures (Altman, 2004). Auscultation requires the use of a stethoscope to listen for internal body sounds, which are usually inaudible to the human ear. The secondary survey helps to establish a baseline health status, and identifies conditions that may or may not relate to the presenting issue.
Below is a short discussion on the body systems assessment regarding Mr. Brown. The neurological assessment would commence with a Glasgow coma scale (GCS) to objectify consciousness. As Mr Brown requires a verbal stimulus to elicit a response, has equal limb strength, and is orientated to person, place and time; he has scored 14/15 (CenterforDiseaseControlandPrevention, 2003). GCS helps to assess for brain injury or neurological depression, and a score of <13 is found to be abnormal (Teasdale & Jennet, 1974).
The assessment continues by testing his pupils, which were found to PEARL, and assessing symptoms such as pain and dizziness; which he has nil complaint of. In regard to Mr. Brown’s cardiovascular system, he is experiencing bi-lateral pitting edema to mid calf, which is a common symptom of congestive cardiac failure (Ely et al. , 2006). He has normal heart sounds and capillary refill times. Due to his past history of CCF and current symptoms it would be appropriate to undertake a focused cardiac assessment.
This assessment would also include inspection of the chest wall for an apical pulse, inspection of the limbs and digits for cyanosis and clubbing, palpation of the pulses for rate, rhythm, strength and equity; also a blood pressure measurement and an electrocardiogram (ECG) (Day et al. , 2009). Mr. Brown’s respiratory assessment reveals that he has bi-basal crackles in his lungs, along with decreased air entry. This is possibly the main cause for his increased work of breathing, and it would be appropriate to undertake a focused assessment on his respiratory system.
The focused assessment would include inspection of the chest wall (for contour and colour), palpation for fremitus, auscultation and percussion of the thorax (front and back), and directed questions relating to the symptoms such as shortness of breath (Massey & Meredith, 2011). Upon inspection, Mr. Brown’s abdomen was soft and tender; with normal bowel sounds. It would now be appropriate to address Mr. Brown’s elevated blood glucose level, as any life threatening conditions have been eliminated. Because Mr.
Brown is not currently on any insulin according to his drug chart, the nurse would need to liaise with a doctor to initiate an intervention. No other gastrointestinal information was supplied. Although Mr. Brown had nil urinary symptoms, it would still be appropriate to undertake a urinalysis. The urinalysis test allows us to detect increased levels of leukocytes, which are a hallmark of infection (McPherson & Ben-Ezra, 2011). The bi-basal crackles heard during the auscultation of the lungs could be due to a possible lung infection. Now that the secondary survey is complete, a social worker should be contacted to arrange care for Mr.
Brown’s wife. Because she is dependent she will be unable to maintain herself in the home, and thus will require assistance. This will also help Mr. Brown psychologically, as he will get peace of mind knowing his wife is being taken care of. This report demonstrated a systematic approach to patient assessment regarding a clinical case study. The importance of both primary and secondary assessments in the examination patients was established. The primary assessment highlighted Mr. Brown’s life threatening respiratory distress and showed the significance of early interventions.
The secondary assessment helped gain significant subjective information that is essential in the diagnostic process. A thorough head-to-toe assessment demonstrated the importance of acquiring more detailed objective information about the patient. Overall systematic assessment is a valuable tool for nurses to help prevent adverse patient outcomes, and to catalyze the overall healing process.