Acute Nursing Care

The assessment of patients forms a major component of the nursing role. It allows the nurse to gain vital information to base the planning and implementation of prioritised care on. A systematic method of assessment is required, that ensures that all areas of assessment are covered and that the assessment and subsequent interventions are as effective and efficient as possible. One method that can be followed for patient assessment is the primary and secondary surveys, with an additional assessment replacing the secondary survey post-operatively. This essay will display the implementation of these methods in the assessment of a trauma patient throughout the peri-operative period. The case study of Mrs Lily Flowers, as outlined in Appendix A, will be used to demonstrate the use of the primary and secondary surveys both pre and post-operatively, commencing with the pre-operative primary survey first.

The first stage of the primary survey is airway management with cervical spine control. Mrs Flowers has a patent airway, signified by her ability to speak to the nurse (Cole 2004). The nurse must immobilise the cervical spine until they can confirm definitive clearance, by the Emergency department, of any spinal damage (Miglietta, Levins & Robb 2002). As Mrs Flowers has a patent airway, is not displaying any signs of airway obstruction and the cervical spine has been cleared of any injury, the primary survey now progresses to the assessment of breathing.

Breathing is assessed by observing the chest wall and pattern of breathing, including the rate and depth of respiration, symmetry of chest wall movements, the use of accessory muscles, rib retraction, nasal flaring, position of comfort and patient colour (O'Reilly 2003). Audible sounds, such as wheezes, stridor or gurgling are listened for and the lungs auscultated for breath sounds and bilateral air entry (O'Reilly 2003). Mrs Flower's respiratory rate of 32 breaths per minute indicates severe tachypnoea (O'Reilly