Systematic Nursing Assessment Case Study

Topics: Patient, Health care, Health care provider Pages: 12 (3473 words) Published: May 19, 2013
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 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...
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