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Systematic Nursing Assessment Case Study

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Systematic Nursing Assessment Case Study
Clinical Case Study

Nursing is a complex and ever expanding profession. 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



References: AdvancedLifeSupportGroup (2001). Acute medical emergencies: the practical approach. London: BMJ Books. Allen, K. (2004). Recognising and managing adult patients who are critically sick. Nursing Times 100, 34-37. AlscoFirstAid (2013).First Aid Resuscitation. Altman, G. (2004). Delmar 's physical assessment skills: Cengage Learning. Anderson, C. (1998). Patient assessment: a systematic approach. Australian Nursing Journal 5, i-iv. Banner, M. J., Kirby, R. R., Kirton, O. C., DeHaven, C. B. & Blanch, P. B. (1995). Breathing frequency and pattern are poor predictors of work of breathing in patients receiving pressure support ventilation. Chest 108, 1338-1344. BetterHealth (2013).First aid-basics: Victorian State Government. CenterforDiseaseControlandPrevention (2003).Glasgow Coma Scale. Edited by D. o. H. a. H. Services. Fort Bragg. Day, R. A., Paul, P., Williams, B., Smeltzer, S. & Bare, B. (2009). Textbook of Canadian Medical-Surgical Nursing, 2nd edn: Brunner & Suddarth. DepartmentofHealthandAgeing (2009).Promoting healthy weight: Australian Government. Domiguez, O. (1997). Stand by your systematic assessment. Emergency 29, 12. Ely, J., Osheroff, J., Chambliss, L. & Ebell, M. (2006). Approach to Leg edema of unclear etiology. Journal of American Board Family Medicine 19, 148-160. Heffner, J. E. (2013). The Story of Oxygen. Respiratory Care 58, 18-31. Hunter, J. & Rawlings-Anderson, K. (2008). Respiratory assessment. Nursing Standard 22, 41-43. KonicaMinoltaSensingInc (2006).How to read SpO2. Edited by K. Minolta. Ramsey, New Jersey. Mancia, G., Ferrari, A., Gregorini, L. & other authors (1983). Blood pressure and heart rate variabilities in normotensive and hypertensive human beings. Circulation Research 53, 96-104. Marcum, P. & Killian, J. (2009). Use of simulation in validating head to toe assessment. Med-Surg Matters 18, 8-11. Massey, D. & Meredith, T. (2011). Respiratory assessment 1: Why do it and how to do it? British Journal of Cardiac Nursing 6, 537-541. McNarry, A. F. & Goldhill, D. R. (2003). Simple bedside assessment of level of consciousness: comparison of two simple assessment scales with the Glasgow Coma scale. Journal of the Association of Anaesthetics of Great Britain and Ireland 59, 34-37. McPherson, R. A. & Ben-Ezra, J. (2011). Basic examination of urine. In Henry 's Clinical Diagnosis and Management by Laboratory Methods. Philadelphia: Elsevier Saunders. Mulhall, D. J. (1977). Systematic self-assessment by P.Q.R.S.T. Psycological Medicine 6, 591-597. Pollak, A. N., Gulli, B., Chatelain, L. & Stratford, C. (2005). Emergency care and transportation of the sick and injured, 9th edn. Sudbury: Jones and Bartlett. Quilliam, S. (2011). 'The cringe report ': Why patients don 't dare ask questions, and what we can do about that. Journal of Family Planning and Reproductive Heath Care 37, 110-112. Safar, P., Escarraga, L. & Chang, F. (1959). Upper airway obstruction in the unconscious patient. Journal of applied physiology 14, 760-746. Stewart, M. A. (1990). Effective physician-patient communication and health outcomes: a review. Canadian Medical Association Journal 301, 968-970. Stoy, W. (2001). Patient puzzle: use systematic assessment. Journal of Emergency Medical Services 26, 24-33; 36-39. Swartz, M. (2002). Textbook of physical diagnosis: History and Examination. Philadelphia: Saunders. Teasdale, G. & Jennet, B. (1974). Assessment of coma and impaired consciousness. Lancet, 81-84. Wardrope, J., Laird, C. & Driscoll, P. (2004). The system of care. Emergency Medicine Journal 21, 89-94. Wardrope, J. & Mackenzie, R. (2004). The system of assessment and care of the primary survey positive patient. Emergency Medicine Journal 21, 216-225.

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